**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to honor Resident (R)8's choices for bathing and showering, for 1 of 2 residents reviewed for Activities of Daily Living (ADL). Findings include: Review of the undated facility policy titled, Activities of Daily Living revealed, staff assists or performs activities of daily living (bathing, dressing, grooming, eating, toileting, etc ) as indicated. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], due to system conversion, original admission date was 06/15/23, with diagnoses including but not limited to: heart failure, morbid obesity, muscle weakness, major depressive disorder, Parkinson's Disease and acquired absence of left leg above the knee. Review of R8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R8 is cognitively intact. Further review of the MDS revealed functional abilities and goals, R8 is dependent; needing assistance taking a shower and bath, and also dependent needing assistance with tub and shower transfer. Review of R8's Care Plan with a revision date of 05/23/24 revealed, a need for extensive assistance to total care by staff members to help with bed mobility, transfers, bathing, and personal hygiene with an approach to offer a shower, shampoo, and nail care at least twice weekly and as needed; also a shower should be performed 2-3 times weekly. Use mechanical lift if indicated. Review of R8's Completed Care Task dated 05/01/24 - 05/30/24 revealed resident had only bed baths during the date range above with exception of dates 05/07/24, 05/09/24, 05/14/24, 05/15/24, and 05/23/24, where no bathing or showering was performed. Review of an undated Manufacturer Manual for a Supply Manual shower bed revealed, there is a 450 pound (lb) weight capacity. Review of an undated Manufacturer Manual for a Direct Supply shower chair revealed, there is a 500 lb weight capacity. During an interview on 05/29/24 at 2:36 PM, R8 revealed she doesn't receive showers. R8 further stated it may be because she is so large, I'm trying to lose weight. During an observation on 05/30/24 at 3:00 PM, with the Executive Director (ED) and the Director of Nursing (DON) revealed, the shower room is a small, tiled room, with shower area, tub and a sink. Inside was one shower bed and two shower chairs. During an observation on 05/30/24 at 3:27 PM, with ED revealed, a shower chair purchased for R8. The shower chair was located in the business office hallway. The chair was white in color, made of PVC pipe, oversized, with pink mesh backing. During an interview on 05/30/24 at 1:04 PM, Certified Nursing Assistant (CNA)2 revealed she was only trained to give R8 bed baths, never trained to give R8 a shower. CNA2 stated R8 never requested a shower. During an interview on 05/30/24 at 2:50 PM, the ED and DON revealed resident gets a bed bath daily. The Unit Manager follows bathing/showering for unit. The ED stated she talked to R8's daughter, R8's daughter told her shower room was too small for her mom. The ED stated, It's very hard for her with two staff members. The DON stated she investigated more, they ordered a shower chair for her in the past. ED and DON both stated, resident stated chair pinched her. During an interview on 05/30/24 at 4:25 PM, R8's daughter revealed, My mother may get a bath later in the day due to low staffing or staff going home. My mother gets a shower once a week, as far as I knows, have not inquired lately. I would never ever say I don't want my mother to take a shower. I have called the facility with concerns in the past about bathing and showering, my mother gets regular bed baths as well. My mother does need help from multiple staff members to perform baths and showers. During an interview on 05/30/24 at 4:35 PM, R8 revealed she never saw a shower chair. Staff introduced her to a shower bed, the bed was too tight for her. R8 stated she washed herself and they helped her to wash. R8 does not remember sitting in a chair and was not pinched by equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate supervision for Resident (R)50, to prevent potential accidents. Findings include: The facility does not have a policy on Supervision for residents. Review of R50's Face Sheet revealed R50 was admitted to the facility on [DATE], with diagnoses including but not limited to: insomnia, altered mental status, post concessional syndrome, contusion of unspecified part of head, and unspecified dementia. Review of R50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/24, revealed R50 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating R50 has severe cognitive impairment. Review of R50's Care Plan with an onset date of 02/08/24, revealed R50 has a potential for wandering with no rational purpose and he enjoys walking down the halls and stopping at resident rooms to speak/converse with other residents. An approach to reach this goal is to observe him for the following behaviors and notify the doctor if persistent or not easily altered (Restlessness, wandering, elopement efforts, fearfulness, agitation, profanity, or other behaviors which may be a threat to myself or others.) Review of R50's Progress Note dated 08/08/23 at 1:58 PM, revealed, Resident will also use profanity. Resident also keeps a pair of tongs in his back pocket as uses as a reacher. Resident will also intrude on the privacy of other residents as he opens closed doors to speak to all without knocking prior to. Res is able to verbalize most of his basic needs in clear speech but has difficulty maintaining a lengthy, coherent conversation. Review of R50's Progress Note dated 11/07/23 at 3:12 PM, revealed, Resident will enter other resident's rooms without invitation to speak even if the door is closed. Behavior is not easily altered even with much encouragement offered to not do so. Review of R50's Progress Note dated 12/25/23 at 9:00 PM, revealed, Resident approached RM [ROOM NUMBER] where a female resides and opened closed door without knocking and female was receiving peri care and female yelled out, Get out of my room, I'm naked. He opened the door a 2nd time and the female said for him to get out. He then yelled at female, **** you, you mother******* *****. He was redirected by staff. RN [Registered Nurse] Supervisor attempted to redirect him on importance of not entering closed doors and just opening the doors. He stated to RN, Yes, I remember you told me not to but I did it anyway. He cursed at staff, ADN walked away. Review of R50's Progress Note dated 01/07/24 at 11:46 AM revealed, Resident do walk down halls opening other resident's room doors and is redirected by staff. Review of R50's Progress Note dated 05/04/24 at 11:23 PM revealed, 2 [NAME] county deputies came and spoke to resident about incident that dayshift nurse reported. Res spoke with deputies but did not remember the incident. Res encouraged to stay on [NAME] End of facility and not go in other residents room. Residents acknowledged but has dementia and roaming around facility is one of his behaviors ever since res arrived at facility. Review of R50's Progress Note dated 05/21/24 at 10:24 AM, revealed, Res will enter the rooms of other residents without invitation to greet them. Resident requires close supervision and much redirection. Res can be easily agitated when redirected and uses strong profanity. Strict limits are set on inappropriate behaviors as they occur. During an interview on 05/30/24 at 2:40 PM, Certified Nursing Assistant (CNA)1 revealed, He goes in other residents' rooms late at night, when they are getting dressed and he doesn't knock he just opens the door. CNA1 states she talked about this with the nurses, but they state that this is his home and they can try what they can. This has continued almost every night since September of last year. Some of the residents enjoy it but there are a lot that don't like the attention. CNA1 further states, [R50] doesn't think he knows what he is doing or means any harm. He goes to the end of the hall and looks out the door. He goes into the male rooms and does the same thing, opens their doors as well. During an interview on 05/30/24 at 3:02 PM, the Social Services Director (SSD) revealed, they don't have a separate dementia unit and they have a resident that invades others privacy, but he has significant cognitive damage and they try to redirect and reeducate the resident to remain clear of certain areas. He is not at a 100% but with constant reminders he is doing a little better. The SSD states, Staff are asked to support and encourage the complainant, not to be aggressive and assist in that process and ask that they understand that they are on two different levels. If they see the resident in that area, try to keep him away from those residents that had concerns, so there is no interaction. We tried to put stop signs across the residents' doors in the past but that was not effective, he would pull them down and it didn't help, they have also in-serviced the staff on the importance of redirecting because he is verbally aggressive. They have not tried any other interventions as reporting to the physician or seeking any assistance from psychological services. The SSD further states, This has been bought to her attention a couple of months or so ago. During an interview on 05/30/24 at 3:31 PM, the Executive Director (ED) states, [R50] does not enter their rooms or harass them, the female residents are just frustrated with him, he will open the door and use profanity at times, when the residents yell to get out, he will yell back at them. The ED revealed she is not aware of him going in anyone's room where anything inappropriate happened. The ED states she has talked with residents one to one about what they decided to do with R50, the residents were hesitant but they were willing to try. The ED states her expectation is for the staff to keep redirecting R50, shut the fire doors of the residents areas that have concerns and try to calmly and nicely redirect him. It is the intent to make sure the residents feel safe wherever they are or remove the factor that is making them feel uncomfortable. The ED concluded, R50 is not mentally, physically, or sexually abusive so in her mind, he has not done any harm.

Based on record reviews, interviews and review of the facility's policy titled, Medication Administration Schedule Policy and Procedure, the facility failed to ensure Resident (R) 32 was free of significant medication errors. R32 did not receive the medication, Nitrostat 0.4 milligrams (mg) as ordered for chest pain for 1 of 4 residents reviewed for Hospitalization. Findings Include: The facility admitted R32 with diagnoses including, but not limited to, Chest Pain, Cerebrovascular Accident, Myocardial Infarction and Hypertension. Review on 3/17/22 at 10:42 AM of the Medication Administration Record (MAR) for R32 revealed a physician's order to give the medication Nitrostat 0.4mgs sublingual every 5 minutes as needed for chest pain x 3 tablets and notify the physician. Further review on 3/17/22 at 10:45 AM of the MAR indicated that R32 did not receive any Nitrostat for her chest pain on 1/8/22, prior to going out to the hospital. No documentation was found on the MAR that R32 had refused the medication. Review on 3/17/22 at 10:45 AM of the Nurses Notes dated 1/8/22 indicated, at 4:03 AM, Called to room per resident, resident complained of severe headache and feeling anxious inside. Vital signs, blood pressure 115/65, heart rate 78, respirations 18 and temperature is 98.2 degrees Fahrenheit and O2 saturation is 98 % on room air. Tylenol administered at this time, awaiting results. The Nurses Note on 1/8/22 at 4:44 AM stated, Went to check on resident, resident sitting on side of bed, continues to complain of not feeling well and also complained of chest pain. Nitro administered at 4:50 AM with no results. The Nurses Note on 1/8/22 at 5:15 AM stated, Second Nitro administered with no effects. MD notified. New order to send to the emergency room for evaluation and treatment. The Nitrostat 0.4 mg was not administered as ordered every five minutes x 3 doses for chest pain. The Nurses Note on 1/8/22 at 7:30 AM states, Emergency Medication Service (EMS) notified of need to transport. EMS in route. R32 returned to the facility on 1/10/22 at 11:11 AM with orders to follow up with a Cardiologist in 2-3 weeks. Review on 3/17/22 at 11:15 AM of the Care Plan for R32 included, Problems with heart function, blood pressure or circulation because of history of high blood pressure, coronary artery disease, high cholesterol, low red blood cells, vascular disease, chest pain, myocardial infarction, and stent placement. An interview on 3/17/22 at 11:20 AM with the Director of Nursing, verified R32 had not received the 3 doses of Nitrostat, as ordered, for Chest Pain. Review on 3/17/22 at 11:30 AM of the facility policy titled, Medication Administration Schedule Policy and Procedure, the policy reads, Registered or licensed practical nurses administer medications upon MD (Medical Doctor) orders in accordance with the Medical and Nurse Practice Act of the state. Under the PRN (as needed) it reads, Nurse must evaluate the resident to determine if dose is needed. The last paragraph states on the policy, All administered medications shall be noted in the resident's eMAR by recording the name of the drug given, dosage, route of administration, and initials of the nurse administering the dose. Any dose refused or not given shall be documented on the eMAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, manufacturer package insert, pharmacy labeling and facility policy, the facility failed to assure that in-use insulin was properly dated as to opening and expiration dates and that expired insulin had been removed from active storage on 1 of 4 medication carts. Findings include: On [DATE] at approximately 10:26 AM, inspection of the East Wing Medication Cart A revealed one opened Novolin R Insulin vial, 100 U (unit)/ml (milliliter), belonging to Resident (R)43, not dated as to date of opening or expiration and one Novolin R Insulin Flexpen 100 U/ml, belonging to R29, dated by the facility as opened [DATE] with no expiration date. A pharmacy label had been attached to each container to indicate opening and expiration date along with specified number of days until expiration once opened. On [DATE] at approximately 10:33 AM, Licensed Practical Nurse 1 confirmed these findings and stated that nurses should check for dating each time medications are administered. The manufacturer (NovoNordisk) package insert dated [DATE] states under Table 2: Storage Conditions and Expiration Dates for NOVOLIN R that in-use (opened) multidose vials are to be discarded after 42 days when stored below 77 degrees F (Fahrenheit) and in-use Flexpens are to be discarded after 28 days when stored below 86 degrees F. Review of the Facility Policy Titled: 5.3 Storage and Expiration Dating of Medications, Biologicals revision date [DATE], PROCEDURE 5. states Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary container (vial, bottle, inhaler) when the medication has a shortened date once opened or opened. 5.3 states If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 18. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.

Based on record reviews, interviews and review of the facility policy titled, Medication Administration Schedule Policy and Procedure, the facility failed to ensure complete and accurate medical records for Resident (R)32 related to documenting medication given for chest pain x 2 doses on the Medication Administration Record. Findings Include: The facility admitted R32 with diagnoses including, but not limited to, Chest Pain, Cerebrovascular Accident, Myocardial Infarction and Hypertension. Review on 3/17/22 at 10:45 AM of the Nurses Notes dated, 1/8/22 at 4:44 AM stated, Went to check on resident, resident sitting on side of bed, continues to complain of not feeling, well and also complained of chest pain. Nitro administered at 4:50 AM with no results. The Nurses Note on 1/8/22 at 5:15 AM stated, Second Nitro administered with no effects. MD notified. New order to send to the emergency room for evaluation and treatment. The Nitrostat 0.4 mg was not administered as ordered every five minutes x 3 doses for chest pain. The Nurses Note on 1/8/22 at 7:30 AM states, Emergency Medication Service (EMS) notified of need to transport. EMS in route. Review on 3/17/22 at 10:46 AM of the Medication Administration Record (MAR) for R32 revealed a physician's order to give the medication Nitrostat 0.4 mg sublingual every 5 minutes as needed for chest pain x 3 tablets and notify the physician. No documentation could be found on the MAR that the Nitrostat sublingual had been administered for the chest pain. An interview on 3/17/22 at 11:20 AM with the Director of Nursing verified R32's MAR was not documented as having received the 2 doses of Nitrostat. Review on 3/17/22 at 11:30 AM of the facility policy titled, Medication Administration Schedule Policy and Procedure, the policy reads, Registered or licensed practical nurses administer medications upon MD (Medical Doctor) orders in accordance with the Medical and Nurse Practice Act of the state. Under the PRN (as needed) it reads, Nurse must evaluate the resident to determine if dose is needed. The last paragraph states on the policy, All administered medications shall be noted in the resident's eMAR by recording the name of the drug given, dosage, route of administration, and initials of the nurse administering the dose. Any dose refused or not given shall be documented on the eMAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R33 was admitted to the facility on [DATE] with diagnoses including, but not limited to; essential primary hypertension, heart failure, and COVID-19. An interview on 3/14/22 at 11:35 AM with R33 revealed that in January of 2022, they were sent to the hospital, due to COVID-19 complications. Record review on 3/15/22 at 10:45 AM of Progress Notes dated 1/15/22 revealed R33 tested positive for COVID-19 and having shortness of breath. The RR and Medical Doctor were notified of new orders. Record review on 3/15/22 at 2:25 PM of a Bed Hold Transfer Agreement dated 1/15/22 revealed R33 was sent to the hospital on 1/15/22 and the transfer agreement was mailed to the RR on 1/27/22. R51 was admitted to the facility on [DATE] with diagnoses including, but not limited to; acute kidney failure, altered mental status, disorders of bladder, and dysphagia. Record review on 3/15/22 at 10:38 AM of a Progress Note dated 1/31/22 revealed Called to room per Certified Nursing Assistant (C.N.A), resident noted to have increased confusion and not responding appropriately to staff. Medical Doctor made aware, 911 called and called Resident Representative, voice message stated unable to receive calls at this time, contacted second contact and made aware of new order to send to Emergency Room. Record review on 3/15/22 at 2:30 PM of a Bed Hold Transfer Agreement dated 1/31/22 revealed R51 was sent to the hospital on 1/31/22 and the transfer agreement was mailed to the appropriate Resident Representative on 2/3/22. Based on record reviews, interviews and review of the facility policy titled, Bedhold Notification/Policy, the facility failed to ensure Resident (R)32, R30, R33 and R51 and/or their responsible party received the Bedhold Notification Policy with the bed hold amount in a timely manner for 4 of 4 residents reviewed for Hospitalizations. Findings include: The facility admitted R32 with diagnoses including, but not limited to, History of Urinary Tract Infections, Pain, Myocardial Infarction, Syncope and Collapse and Long Term Use of Antithrombotics and Antiplatelets. Review on 3/15/22 at 1:30 PM of the medical record for R32 revealed confirmation of a hospital stay starting 1/8/22 and returning to the facility on 1/10/22. Review of the Bed Hold Notification mailed to the responsible party was dated 1/13/22, 3 days after R32 returned from the hospital. An interview on 3/15/22 at 1:30 PM with the Business Office Manager confirmed that R32 was transferred to the hospital on 1/8/22 and returned on 1/10/22 and also that he mailed the Bedhold Notification to the responsible party for R32 on 1/13/22. The BOM confirmed the notification did not include bedhold amounts, as required. Review on 3/15/22 at 1:45 PM of the facility policy titled, Bedhold Notification Policy, states, This Nursing Center will hold a bed for a resident transferred from the facility as follows: Medicaid Resident: Medicaid residents are eligible for bedhold up to ten (10) days while in the hospital . If the hospitalization exceeds the allotted ten (10) days bedhold period that Medicaid allows, will be discharged from the facility as of day eleven (11). This determination means that if the resident is not back in the facility by midnight (12:00 AM) on day eleven (11), the resident will have exceeded their bedhold and will be discharged . You can call and request that additional days be added to the bedhold. However these additional days will be billed privately, and the resident's family will be responsible for the payment of the additional days. This request must be made to our Business Office no less than 3 days of the resident exceeding their allotted ten (10) days. If a resident exceeds their allotted 10 days and additional days are not requested, again the resident will be discharged from the facility. There is no amount informing residents or resident's representatives how much each day will cost them if they happen to exceed the 10 days, therefore would not be able to make a decision or arrangements for the cost. On 3/15/22 at approximately 3:45 PM, a review of the medical record for R30 revealed that on 2/3/22 at 10:00 PM, the Resident Representative (RR) had been notified and Bed hold completed. Further review revealed on 2/3/22, R30 had been sent to the local hospital on 2/3/22 at 10:16 PM, due to increased lethargy and decreased blood pressure. R30 had been admitted to the facility on [DATE] with diagnoses including, but not limited; to cerebral palsy and epilepsy. On 3/16/22 at approximately 10:25 AM, a review of the facility provided bedhold notice for R30 revealed Date to Hospital: 2/3/22 and Date Mailed to RR: 2/7/21 (2022). There was no listing in the bedhold document for the charge amount, if additional days were requested.