Based on interview, record review, and policy review, the facility failed to recognize and thoroughly investigate an injury of unknown origin for one of 28 sampled residents (Resident (R)52). This had the potential to cause residents to be at risk of abuse when injuries of unknown origin were not fully investigated. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, with a revision date of 09/2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, theft, or misappropriation of resident property were reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Review of R52's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 02/21/24 with medical diagnoses that included traumatic rupture of other ligament of the left wrist, need for assistance for personal care, and deaf non-speaking. Review of R52's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 08/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R52 was severely cognitively impaired. Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 06/30/24 at 2:53 PM, revealed, . lethargic today and became agitated each time staff attempted to provide care and change his brief . Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 07/01/24 at 12:12 PM, revealed, . Resident is alert and took morning medications. Resident did not eat breakfast. NP [Nurse Practitioner] was notified. Resident was groaning of pain in right arm when trying to move arm. NP assessed resident and waiting on new orders. Will continue to monitor resident . Review of R52's Progress Notes, under the Prog Notes tab in the EMR, dated 07/01/24 at 10:43 AM, and written by the NP2 revealed, . increased agitation, altered mental status from baseline. Nursing staff report he is 'not himself the past days'. ls not his usual happy self, he is obtunded, non-interactive with staff, is not eating and only drinking a small amount of fluids. Unable to move [right] arm, grimaces, and moans with pain when touching. Recommendations included x-ray of right shoulder and arm. Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 07/02/24 at 3:20 PM, revealed, . [R52] right arm flaccid and very painful. Patient can no longer reposition in bed or sit up in order to transfer to [wheelchair] R52 can no longer feed self-due to right arm flaccid/pain. X-ray of right arm yesterday negative . EMS transferred patient to [hospital name withheld] at approximately l0:00 today for further testing . Review of R52's Progress Notes, under the Prog Notes tab in the EMR, dated 07/02/24 at 9:05 PM, and written by the NP2, revealed, . Today [R52] found lying in bed continues to have acute discomfort with right upper extremity. X-ray results reviewed. Patient appears to be slightly more alert today with eyes open tracking in order to provide a smile to assess for symmetry. Speech continues to be incomprehensible; however, this [was R52's] baseline. Pain in right upper extremity was increasing and more generalized. Previous exam showed more localized discomfort and easily palpable, however today, [R52] complains of pain in his fingertips with any type of tactile stimulus. Radial pulses palpable capillary refill in fingernails tips of fingers is less than 3 seconds, increased swelling from shoulder to arm, not warm or hot to touch skin. it was decided to have patient transported to [hospital name withheld] for an additional high-level evaluation . Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 07/03/24 at 4:33 PM, revealed, [R52] returned to [the facility] today at 8:00 AM [R52] diagnosed with [fracture] of right humerus and right clavicle. [R52] receiving Tylenol for pain and new order written for Noro 5/325 every 8 hr. Patient has right arm in sling. [R52] was a total assist with all ADL's (Activities of Daily Living). During an interview on 10/03/24 at 2:15 PM, Registered Nurse (RN)1 explained on the morning of 07/01/24, R52 was crying out in pain when his right arm was touched and was guarding his right arm. RN1 stated NP2 ordered an x-ray and tried to find out what happened that the arm was so painful, but the reason for the pain in the right arm was never determined. RN1 stated no one reported a fall or that R52 was hitting a wall. RN1 stated CNA staff did report when R52 was in a combative mood, he would strike out at staff when attempting to provide care. RN1 stated after the second x-ray, R52 was found to have a fracture and was fitted for a sling for the right arm. During an interview on 10/04/24 at 9:44 AM, the Certified Occupational Therapy Assistant (COTA) 1 explained treatment was started for R52 due to the clavicle fracture. COTA1 stated R52 was treated to decrease the pain for ADLs, like putting an arm through the sleeve of a shirt. COTA1 described R52's fracture as being like what would happen if someone had extended their arm to stop a fall. On 10/04/24, the Administrator was asked to provide the facility's investigation of the fracture. Review of the facility's investigation revealed the facility began the investigation when R52 had signs and symptoms of pain to the right arm. The investigation revealed the R52 had some combative episodes prior to onset of pain. Staff caring for the resident were interviewed, and no incidents were reported other than the combativeness. The resident's roommate was interviewed and denied knowledge of any incidents. The investigation concluded the pain was from the resident being combative and striking out at staff during cares; however, there was no documentation to show the facility investigated the fracture as an injury of unknown origin after learning of the fracture. During an interview on 10/04/24 at 12:37 PM, the Administrator, who was the facility's Abuse Coordinator, explained when he learned of R52's right arm pain, he began an investigation into the pain. The Administrator stated through the interview process, CNA staff explained that the resident was combative and striking out at staff when attempting to provide care for the resident. He stated R52 was not communicative and could not answer any questions about the reason for the pain in his right arm. The Administrator stated the pain began after 'something occurred' on 06/30/24 and a portable x-ray was obtained on 07/01/24, and the results were negative for fracture. The Administrator stated when the investigation began, he did not consider the pain might be from an injury; therefore, he did not trigger an abuse investigation for injury of unknown origin. During an interview on 10/04/24 at 12:55 PM, the Administrator confirmed that he did not further investigate after the fracture was identified. He stated he had felt the investigation into the pain was all that was needed. The Administrator confirmed the type of investigation done initially was not as in depth as an abuse investigation, and the investigation should have been an investigation for an injury of unknown origin instead of assuming the previous investigation was complete. The Administrator confirmed the facility's physiatrist and the interdisciplinary team were not involved in the investigation and should have been.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident (Resident (R) 13) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment, planning for resident care, and potentially affect post facility care of the resident. Findings include: Review of the October 2023 Resident Assessment Instrument (RAI) Manual, page J-36 revealed, Planning for Care -Identification of residents who are at high risk of falling is a top priority for care planning. -Falls indicate functional decline and other serious conditions such as delirium, adverse drug reactions, dehydration, and infections. -External risk factors include medication side effects, use of appliances and restraints, and environmental conditions. -A fall should stimulate evaluation of the resident's need for rehabilitation or ambulation aids and of the need for monitoring or modification of the physical environment. -It is important to ensure the accuracy of the level of injury resulting from a fall. Since injuries can present themselves later than the time of the fall, the assessor may need to look beyond the ARD to obtain the accurate information for the complete picture of the fall that occurs in the look back of the MDS. On page J-37: Steps for Assessment . 2. If this is not the first assessment . the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment. 3. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls. 4. Review nursing home incident reports and medical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury. 5. Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record. 6. Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment. Review of R13's admission Record, from the electronic medical record (EMR) Profile tab, showed a facility admission date of 06/10/21 with medical diagnoses that included type II diabetes, dementia with agitation, degenerative disease of the nervous system, polyneuropathy, osteoporosis, anxiety disorder, and insomnia. Review of R13's EMR Evaluations tab showed post fall reviews completed on 03/17/24, 07/28/24 and 09/09/24. Review of R13's quarterly MDS, with an Assessment Reference Date (ARD) of 05/27/24, showed a coding of one fall with minor injury since admission or last assessment. Review of R13's annual MDS, with an ARD of 08/20/24, showed R13 had no falls since admission or the last assessment. Review of R13's EMR Progress Notes from the Progress Notes and dated 07/28/24 at 7:30 AM, revealed, . upon assessment, resident was noted on the floor laying on her left side on the fall mat. the bed was in the lowest position with the call bell still attached . the resident wasn't able to tell the writer how she ended up on the floor r/t [related to] her cognition impairment . During an interview on 10/04/24 at 2:00 PM, the MDS Coordinator (MDSC) reviewed the Post Fall Reviews in the EMR Evaluations tab and commented, There was one dated 07/28. The MDSC reviewed the EMR Progress Notes and stated, There is a nurse's note that she fell on 07/28. She then reviewed the annual MDS with an ARD of 08/20/24 and stated, There were no falls coded, and that was coded incorrectly. At 2:15 PM, The MDSC confirmed that the facility uses the Resident Assessment Instrument (RAI) Manual as the facility's policy related to MDS accuracy. During an interview on 10/04/24 at 4:25 PM the Administrator stated an expectation that MDS assessments would be accurately coded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure the care plan regarding resuscitation was updated for one of one resident (Resident (R) 111) out of 28 residents reviewed. The failure to keep a care plan current could affect the appropriateness of care provided in the case of a respiratory or cardiac arrest. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revealed, . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. Review of R111's electronic medical record (EMR) header bar on all pages showed a DNR [Do Not Resuscitate] status which meant R111 had chosen to not have chest compressions and rescue breathing performed on her behalf in the case of a respiratory failure or heart attack. Review of R111's EMR Miscellaneous tab showed a DNR order signed by her Representative on [DATE]. Review of R111's EMR Orders tab showed a physician order for DNR status dated [DATE]. Review of R111's Care Plan from the EMR Care Plan tab showed: Full Code Resident has made an informed decision or given authority to the person(s) acting on their behalf that if their heart stops beating and/or breathing stops that they do want cardiopulmonary resuscitation (CPR) Date Initiated: [DATE] -To restart heart/ breathing Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] -Consent form is read and signed by the resident or authorized representative and placed in the residents' chart Date Initiated: [DATE] -FULL CODE Date Initiated: [DATE] -If found without heartbeat and/or respiration the code status will be confirmed by looking at the chart then notifying or having another person notify 911 while CPR [cardiopulmonary resuscitation] is started and continued until EMS [Emergency Medical Services] arrives and intervenes Date Initiated: [DATE] -The residents' choice to have CPR in the event that the heart and/or breathing stops is obtained during the admissions process Date Initiated: [DATE] Review of R111's significant change of status assessment Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE], showed she was coded as having a terminal diagnosis and was receiving hospice services. In an interview on [DATE] at 11:10 AM, the Director of Nursing (DON) viewed the EMR DNR status on the header bar of the screen, the DNR Physician's order, and the care plan showing full code and stated, The care plan should have been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide restorative nursing services to one of one resident (Resident (R) 112) reviewed for restorative nursing services out of a total sample of 28. This had the potential for increased contractures and a decrease in mobility. Findings include: Review of the policy titled, Activities of Daily Living (ADL), Supporting, revised 03/2018 revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable . Care and services to prevent and/or minimize functional decline . Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice . The facility did not have a policy for Restorative Nursing. Review of R112's admission Record, from the EMR Profile tab, showed an original admission date of 10/30/23 and re-admission on [DATE] with a primary medical diagnosis of acute osteomyelitis of the right tibia and fibula. Comorbidities included generalized muscle weakness, abnormal posture, need for assistance with personal care, pain due to internal orthopedic prosthetic devices, contracture to right shoulder, contracture of muscle (multiple sites), paraplegia, osteoarthritis, fracture of neck, anterior cord syndrome at C7 level of cervical spinal cord, fracture of fourth lumbar vertebra, fracture of fifth lumbar vertebra, fracture of sacrum, and fracture of lower end of right radius. Review of R112's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicative of being cognitively intact; functional limitation in range of motion to one side of upper extremity; and bilateral impairment to lower extremities. Review of R112's Clinical Physician Orders, located in the electronic medical record (EMR) under the Orders tab, revealed no orders for range of motion assistance. Review of R112's Care Plan, located in the EMR under the Care Plan tab and revised 05/10/24, revealed R112 had actual ADL [activities of daily living]/mobility decline and requires assistance related to s/p [status post] hospitalization for MVC [motor vehicle collision] with cervical spine fracture, right radius fx [fracture], sacral fx, quadriplegia . spasticity, bedbound. I admitted with no movement bilateral lower extremities, RUE [right upper extremity]. Minimal movement. I c/o [complain of] pain and refuse passive range of motion [PROM] to wrist and hand . [NAME] back brace wear while up out of bed as tolerated . The resident has an alteration in musculoskeletal status due to MVA [motor vehicle accident] resulted in contractures abd [sic] impaired mobility, he has dx [diagnosis] of contracture, right shoulder, contracture of muscle, multiple sites, contracture, right shoulder, contracture of muscle, multiple sites, contracture, right hand, cramp and spasm [sic] He is at risk for further complications . Interventions included dependence of two staff for bed mobility and transfers, offloading heels with offloading boots and/or pillows as tolerated, pressure reduction cushion, anticipate and meet needs, and educate on joint conservation techniques. Review of R112's undated Visual/Bedside [NAME] Report, provided by the facility, included [NAME] back brace - wear while up out of bed as tolerated, anticipate and meet needs, be sure call light is within reach and respond promptly to all requests for assistance, offload heels with pressure offloading boots and/or pillows as tolerated, and dependence on two staff members for bed mobility, turning, and repositioning. Review of R112's PT [Physical Therapy] Discharge Summary, dated 05/22/24 and provided by the facility, included long-term goals including improvement of PROM for left knee extension to 25 degrees in order to improve range of motion (ROM) and prevent further risk of joint contractures. Comments included, Nsging [nursing]/CNAs [Certified Nursing Aides] to be independent with PROM and prolong stretches in all available planes in order to improve ROM and prevent further risk of joint contractures. Training to caregivers included, PROM/prolong stretches to LEs [lower extremities] and knee extension splint for left LE. Review of R112's OT [Occupational Therapy] Summary, dated 05/22/24 and provided by the facility, included long-term goals to include increasing PROM right shoulder flexion to 25 degrees in order to increase independence with ADLs/IADLs (instrumental ADLs which are activities that support daily life and interactions with environment). Comments included, Nursing staff to be independent with PROM to R (right) UE (upper extremity) in all available planes in order to improve ROM and prevent further risk of joint contractures. Training included instructing nursing caregivers in PROM techniques to RUE (right upper extremity) in all functional planes in order to prevent decline from current level of skill performance with 100% carryover demonstrated. Patient response was, Patient responded positively to passive techniques to stimulate functional performance and enhance safety to prevent further decline. During an observation and interview on 10/02/24 at 8:42 AM, R112 stated that he was in a motorcycle accident and was hospitalized for a month and a half prior to coming to the facility for rehabilitation services. R112 stated that his legs were paralyzed, he had limitation of movement to his right arm, and his left arm had slight impairment but had improved since admission. He reported that his left leg had less range of motion than the right, and the right knee had slight movement. He stated he was unable to move BLE. When asked if staff turned and repositioned him or provided range of motion exercises, he stated that only happened when they did wound care which required movement of his BLE. R112 stated when staff transferred him to his geriatric chair, they had to reposition him. R112 denied refusal of care and stated that staff do not offer him active ROM assistance. During the observation, R112 demonstrated to this surveyor that he could slightly move his right knee, was able to move BUE with limitations, and was wearing soft padded boots for pressure reduction. During an interview on 10/03/24 at 2:51 PM, the Director of Rehabilitation (DOR) reported that R112 received occupational and physical therapy services from 05/15/24-05/22/24, and PT was doing ROM with the resident's left knee to increase the degree of extension and PROM stretching to prevent further risk of joint contractures, OT was working on upper and lower body exercises to reduce contractures, and R112 was reported to have self-limiting behaviors due to pain. The DOR stated she spoke with R112 last week, and he said he would like to come back on therapy services. The DOR stated the facility did not have a restorative nursing program, but when a resident completed therapy, their staff provided training/in-services to all nursing staff on the first and second shifts so that they were able to provide AROM/PROM as appropriate. The DOR contacted Physical Therapist (PT) 1 by phone during the interview. PT1 stated that she had provided training to some of the nursing staff but had not documented it and did not have any signature sheets available. When this surveyor asked about orders for AROM/PROM related to therapy recommendations, the DOR stated they do not put in any orders and was not sure who was responsible for that. The DOR stated her recommendation would be for R112 to receive PROM once daily. During an interview on 10/03/24 at 4:09 PM, Registered Nurse (RN) 2 stated that the facility did not have a restorative nursing program but that the CNAs were responsible for providing AROM. She stated she was not aware of any residents that had orders for AROM, but if the residents ask for it, they receive it. During an interview on 10/04/24 at 11:44 AM, Certified Nursing Assistant (CNA) 2 stated that the facility did not have a restorative nursing program and R112 was not receiving AROM/PROM by the CNAs. CNA2 reported the CNAs only do stretches (PROM) if there was an order for it and was included on the resident's POC (Plan of Care located in the EMR). During an interview on 10/04/24 at 11:54 AM, CNA3 stated that R112 used to receive therapy services. CNA3 stated that when residents complete therapy, if they are to receive AROM/PROM, the therapy department would provide in-services to the staff. CNA3 stated that R112's legs were stiff and that when he allowed it, she would help him to stretch his legs. During an observation and interview on 10/04/24 at 12:20PM with R112, the resident was in bed with soft boots in place for pressure reduction to heels. R112 stated that staff were not offering PROM, and he could only do AROM with his BUE. R112 stated that he felt his joints were stiffer due to them not being moved around since his therapy was completed in May 2024. During an interview on 10/04/24 at 2:25 PM, Licensed Practical Nurse (LPN1) confirmed that R112 was not receiving restorative nursing services or preventive stretching because therapy would have had to enter an order for the resident to receive this type of care from the nursing department. During an interview on 10/04/24 at 7:48 PM, the Director of Nursing (DON) stated that the nursing department had not received documentation or recommendations from the therapy department for R112 to receive AROM. She stated she felt it was an internal problem due to the facility not having a restorative nursing program. She stated if the aides or nurses were to provide AROM/PROM, they would have to be trained/in-serviced by the therapy team. The DON stated that she had checked with the Director of Staff Development (DSD) who reported they were unable to locate any staff training/in-services provided by the therapy department. Additionally, the DSD did not have any training or in-services related to R112. The DON stated that in order for R112 to receive AROM/PROM, there would be an order that would then generate a task for the CNAs. The DON confirmed that R112 did not have any orders in place for AROM/PROM but should have based off of discharge therapy recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure eight of nine residents and their representatives (Resident (R) 22, R26, R42, R56, R94, R106, R111, R112 and R113) reviewed for facility initiated emergent hospital transfer from a total sample of 28 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Additionally, the Ombudsman was not notified of hospital transfers for R22, R42, R94, R112, and R113. Findings included: Review of the facility policy titled, Transfer or Discharge, Facility-Initiated, dated 2001, revealed, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected .Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident . c. An immediate transfer or discharge is required by the resident's urgent medical needs . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable . Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments . 1. Review of R22's admission Record, from the electronic medical record (EMR) Profile tab, showed an admission date of 09/27/10 with a primary medical diagnosis that included metabolic encephalopathy. Review of R22's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/12/24, showed a Brief Interview for Mental Status (BIMS) score of four out of a possible 15, indicative of severe cognitive impairment. Review of R22's Progress Notes tab, dated 01/10/24 at 11:04 AM, revealed that R22 was experiencing a change in mental status, refusing medications for two days, and hallucinating. The resident was taken to the emergency department. Review of R22's Progress Notes tab, dated 01/15/24 at 3:01 PM, revealed that R22 returned to the facility. Review of R22's Progress Notes tab, dated 03/11/24 at 6:45 PM, revealed that R22 had sustained a fall resulting in a wound to the left lower leg. The resident was taken to the emergency department. Review of R22's Progress Notes tab, dated 03/12/24 at 1:45 AM, revealed that R22 returned to the facility at that time with a dressing to the left lower leg and ice pack applied to hematoma to the right mid leg. Review of R22's Progress Notes tab, dated 10/01/24 at 9:56 AM, revealed that R22 was experiencing a change of condition and was sent to the hospital for evaluation. Review of R22's Progress notes tab, dated 10/03/24 at 4:30 PM, revealed that R22 returned to the facility at 4:30 PM. Review of R22's Documents, located under the Miscellaneous tab, did not include written notifications of emergent transfers and discharges to the hospital emergency department for R22 and/or their resident representative. The facility documents titled, Admission/Discharge To/From Report, for January through March 2024 hospital transfers, were not provided to this Surveyor for review. During an interview on 10/04/24 at 10:45 AM, the Social Services Director (SSD) confirmed that the Ombudsman was not notified of R22's hospitalizations on 01/10/24 and 03/11/24 but should have been. 2. Review of R26's admission Record, from the EMR Profile tab, showed an admission date of 02/15/21 and most recent re-admission on [DATE] with a primary medical diagnosis of non-ST elevation (NSTEMI) myocardial infarction (a type of heart attack that happens when a part of the heart does not get enough oxygen). Review of R26's quarterly MDS, with an ARD of 08/16/24, showed a BIMS score of 14 out of a possible 15, indicative of being cognitively intact. Review of R26's Progress Notes tab, dated 02/13/24 at 8:21 AM, revealed that R26 was experiencing low oxygen saturation levels, wheezing, and generalized abdominal pain with nausea and vomiting. The resident was taken to the emergency department. Review of R26's Progress Notes tab, dated 02/24/24 at 5:56 PM, revealed that R26 returned to the facility with diagnoses including angina (chest pain), pulmonary fluid overload, and pneumonia. Review of R26's Documents, located under the Miscellaneous tab, did not include written notification of an emergent transfer and discharge to the hospital emergency department. The facility document titled, Admission/Discharge To/From Report for February 2024 hospital transfers was not provided to this Surveyor for review. 3. Review of R42's admission Record, from the EMR Profile tab, showed an admission date of 12/15/20 and most recent re-admission on [DATE] with a primary medical diagnosis of senile degeneration of the brain. Review of R42's significant change MDS, with an ARD of 06/28/24, showed a BIMS score of three out of a possible 15, indicative of severe cognitive impairment. Review of R42's Progress Notes tab, dated 06/12/24 at 3:14 PM, revealed that R42 sustained a fall from his wheelchair and sustained a laceration over the right eye. The resident was taken to the emergency department. Review of R42's Progress Notes tab, dated 06/12/24 at 10:58 PM, revealed that R42 returned to the facility status post fall with negative computed tomography (CT) results of the brain. Review of R42's Progress Notes tab, dated 06/19/24 at 8:38 PM, revealed that R42 sustained a fall from his wheelchair and was experiencing blood spewing from the nasal cavity. The resident was taken to the emergency department. Review of R42's Progress Notes tab did not include R42 returning to the facility; however, the Census tab indicated R42 returned to the facility on [DATE]. Review of R42's Progress Notes tab, dated 06/23/24 at 12:33 PM, revealed that R42 sustained a fall from his wheelchair at 5:45 AM and was experiencing nasal bleeding. The resident was taken to the emergency department. Review of R42's Progress Notes tab, dated 06/23/24 at 12:34 PM, revealed that R42 returned to the facility at 10:45 AM with diagnoses including closed head injury and a nose fracture. Review of R42's Documents, located under the Miscellaneous tab, did not include written notifications of the emergent transfers and discharges to the hospital emergency department. Review of the facility document titled, Admission/Discharge To/From Report, dated 07/01/24 and provided by the Social Services Director (SSD), did not include notification to the Ombudsman for R42's hospital transfers on 06/12/24, 06/19/24, and 06/23/34. During an interview on 10/04/24 at 10:53 AM, the SSD stated that when residents are sent to the emergency department and return before midnight, the Ombudsman was not notified of the transfer/discharge, and if residents remain in the hospital past midnight, then the census was to be updated by the business office manager of hospitalization status. The SSD confirmed that the Ombudsman was not notified of R42's June 2024 hospital visits but should have been. 4. Review of R56's admission Record, from the EMR Profile tab, showed an admission date of 06/20/20 and most recent re-admission on [DATE] with a primary medical diagnosis of hypotension. Review of R56's quarterly MDS, with an ARD of 07/26/24, showed a BIMS score of 15 out of a possible 15, indicative of being cognitively intact. Review of R56's Progress Notes tab, dated 02/14/24 at 10:52 PM, revealed that R56 had experienced vomiting with blood clots. The resident was taken to the emergency department. Review of R56's Progress Notes tab, dated 02/16/24 at 10:410 PM, revealed that R56 returned to the facility at that time with diagnoses including gastrointestinal ulcers and hernia. Review of R56's Progress Notes tab, dated 04/23/24 at 4:19 PM, revealed that R56 was sent out to dialysis that morning and was nauseated and unable to follow simple commands. The resident was taken to the emergency department. Review of R56's Progress Notes tab, dated 05/01/24 at 10:48 PM, revealed that R56 returned to the facility at that time. Review of R56's Progress Notes tab, dated 05/10/24 at 12:25 PM, revealed that R56 was experiencing vomiting, lethargy, and an erratic pulse. The resident was taken to the emergency department. Review of R56's Progress Notes tab, dated 05/12/24 at 5:40 PM, revealed that R56 returned to the facility at that time. Review of R56's Documents, located under the Miscellaneous tab, did not include written notification of an emergent transfer and discharge to the hospital emergency department. Review of the facility document titled, Admission/Discharge To/From Report, dated 06/05/24 and provided by the SSD, did not include notification to the Ombudsman for hospital transfer on 05/10/24. The facility documents titled, Admission/Discharge To/From Report for February and April 2024 hospital transfers were not provided to this Surveyor for review. During an interview on 10/04/24 at 10:49AM, the SSD confirmed that the Ombudsman was not notified of R56's hospitalizations on 02/14/24, 04/23/24, and 05/10/24 but should have been. 5. Review of R94's admission Record, from the EMR Profile tab, showed an admission date of 02/21/22 with a primary medical diagnosis of peripheral vascular disease. Review of R94's quarterly MDS, with an ARD of 08/26/24, showed a BIMS score of zero out of a possible 15, indicative of severe cognitive impairment. Review of R94's Nursing: Bedhold Confirmation document, provided by the facility and dated 02/14/24, revealed that R94 was transferred to the emergency department. Review of R94's Census tab did not include hospitalization dates for February 2024. Review of R94's Einteract Transfer Form V5 document, provided by the facility and dated 07/12/24, revealed that R94 was transferred to the emergency department. Review of R94's Census tab indicated that R94 returned to the facility on [DATE]. Review of R94's Progress Notes tab, dated 08/15/24 at 12:05 PM, revealed that R94 had experienced behavioral problems, including throwing multiple items in his room. The resident was taken to the emergency department. Review of R94's Progress Notes tab, dated 08/24/24 at 2:14 PM, revealed that R94 returned to the facility at that time with admission to hospice services. The facility document titled, Admission/Discharge To/From Report for February 2024 hospital transfers was not provided to this Surveyor for review. During an interview on 10/04/24 at 11:21 AM, the SSD confirmed that the Ombudsman was not notified of R94's 02/14/24 hospital visit but should have been. 6. Review of R111's admission Record, from the EMR Profile tab, showed an original admission date of 05/09/23 and re-admission on [DATE] with a primary medical diagnosis of unspecified severe protein -calorie malnutrition. Review of R111's significant change MDS, with an ARD of 08/12/24, showed a BIMS score of 99 out of a possible 15, indicative of severe cognitive impairment. Review of R111's Progress Notes tab, dated 01/23/24 at 1:32 PM, revealed that R111 had experienced abnormal vital signs and altered mental status. The resident was taken to the emergency department. Review of R111's Progress Notes tab, dated 01/23/24 at 6:31 PM, revealed that R111 returned to the facility with no new orders. Review of R111's Progress Notes tab, dated 02/24/24 at 7:46 PM, revealed that R111 had experienced seizure-like activity. The resident was taken to the emergency department. Review of R111's Census tab revealed that R111 returned to the facility on [DATE]. Review of R111's Progress Notes tab, dated 04/30/24 at 10:01 PM, revealed that R111 had experienced a fall. The resident was taken to the emergency department. Review of R111's Progress Notes tab, dated 05/01/24 at 4:30 AM, revealed that R111 returned to the facility. Review of R111's Progress Notes tab, dated 05/18/24 at 12:41 PM, revealed that R111 had experienced a change in condition. The resident was taken to the emergency department. Review of R111's Progress Notes tab, dated 05/18/24 at 5:55 PM, revealed that R111 returned to the facility. Review of R111's Progress Notes tab, dated 07/29/24 at 2:28 PM, revealed that R111 had experienced a change in condition as evidenced by passing out on the commode. The resident was taken to the emergency department. Review of R111's Progress Notes tab dated 07/30/24 at 9:03 PM revealed that R111 returned to the facility at that time with admission to hospice services. Review of R111's Documents, located under the Miscellaneous tab, did not include written notification of an emergent transfer and discharge to the hospital emergency department. During an interview on 10/04/24 at 11:11 AM, the SSD confirmed the resident's representative had not been informed in writing of the reason for the resident's transfer to the hospital. 7. Review of R112's admission Record, from the EMR Profile tab, showed an original admission date of 10/30/23 and re-admission on [DATE] with a primary medical diagnosis of acute osteomyelitis of the right tibia and fibula. Review of R112's quarterly MDS, with an ARD of 08/12/24, showed a BIMS score of 14 out of a possible 15, indicative of being cognitively intact. Review of R112's Progress Notes tab, dated 05/24/24 at 11:50 PM, revealed that R112 had experienced a change in condition as evidenced by nausea and vomiting. The resident was taken to the emergency department. Review of R112's Progress Notes tab, dated 05/25/24 at 6:56 AM, revealed that R112 had returned to the facility with new diagnoses including urinary tract infection. Review of R112's Progress Notes tab, dated 06/22/24 at 9:30 PM, revealed that R112 had experienced a change in condition as evidenced by nausea as the nurse lowered the head of the bed. The resident was taken to the emergency department. Review of R112's Progress Notes tab, dated 06/25/24 at 6:59 PM, revealed that R112 had returned to the facility with new diagnoses including urinary tract infection. The facility document titled, Admission/Discharge To/From Report, dated 06/05/24 and provided by the SSD did not include notification to the Ombudsman for R112's hospital transfers on 05/24/24 and 06/22/24. During an interview on 10/04/24 at 10:52 AM, the SSD confirmed that the Ombudsman was not notified of R112's 05/24/24 and 06/22/24 hospital visits but should have been. During an interview on 10/04/24 at 12:29 PM, R112 stated that he had no know was not provided any paperwork that he was aware of regarding why he went to the hospital or how to appeal the decision if needed. 8. Review of R113's admission Record, from the EMR Profile tab, showed an original admission date of 12/27/23 and re-admission on [DATE] with a primary medical diagnosis of nontraumatic intracerebral hemorrhage in hemisphere, subcortical. Review of R113's PPS- Part A Discharge MDS, with an ARD of 08/30/24, showed a BIMS score of 10 out of a possible 15, indicative of being moderately cognitively impaired. Review of R113's Progress Notes tab, dated 06/10/24 at 9:22 AM, revealed that the resident was unresponsive and drooling. The resident was taken to the emergency department. Review of R113's Progress Notes tab, dated 06/14/24 at 3:47 PM, revealed that R113 returned to the facility with a new diagnosis of acute ischemic stroke. Review of R113's Progress Notes tab, dated 07/23/24 at 12:19 PM, revealed R113 had changes in behavior and mental status. The resident was taken to the emergency department. Review of R113's Progress Notes tab, dated 07/23/24 at 10:51 PM, revealed that R113 had returned to the facility with a new diagnosis of Covid and UTI. Review of R113's Progress Notes tab, dated 08/02/24 at 10:45 AM, revealed R113 had sustained a fall and had discoloration to the right eyebrow, right cheek, right shoulder, and right knee. The resident was taken to the emergency department. Review of R113's Progress Notes tab, dated 08/02/24 at 7:18 PM, revealed that R113 had returned to the facility. The facility document titled, Admission/Discharge To/From Report, dated 07/01/24, 08/01/24, and 09/06/24 and provided by the SSD, did not include notification to the Ombudsman for R113's hospital transfers on 06/10/24, 07/23/24, and 08/02/24. During an interview on 10/04/24 at 10:55 AM, the SSD confirmed that the Ombudsman was not notified of R113's 06/10/24 hospital visit but should have been, and hospital visits on 07/23/24 and 08/02/24 were not reported to the Ombudsman due to R113 returning to the facility before midnight on those dates. During an interview on 10/03/24 at 5:40 PM, the Administrator revealed that the facility had documentation for R22, R26, R42, R56, R94, R111, R112, and R113 of bed-hold notifications but did not have transfer notifications that were provided to the resident and/or the residents' representatives. The Administrator stated he felt that the residents and their representatives were well aware of the resident's status upon transfer to the hospital due to the nurses calling the representatives upon transfer to the hospital. The Administrator did not confirm or deny that the facility should have provided a written notification to the resident/representative at the time of transfer to the hospital. During an interview on 10/04/24 at 9:52 AM, Medical Records (MR) stated that when a resident was sent out to the hospital, the Business Office Manager (BOM) updated the Census line in the EMR, and her responsibility was to send out the Bed Hold notification, but she did not send out Transfer Notifications and was not sure whose responsibility that was. During an interview on 10/04/24 at 8:05 PM, the Administrator and Director of Nursing stated a joint expectation that written notices of transfer and discharge would be provided (to the Resident and/or Representative) at the time of transfer or as reasonably practicable in the case of an emergent transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, observation, and interviews, the facility failed to promote the dignity of a resident who was observed with staff standing while assisting the resident to eat a meal for 1 Resident (R)118, of 1 resident reviewed for dignity. Findings include: Review of the facility's policy titled, Assistance with Meals, dated March 2022, revealed .Residents Requiring Full Assistance: .2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals . Review of R118's admission Record located in the resident's Electronic Medical Record (EMR) under the Profile tab revealed R118 was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia, and encephalopathy. Review of R118's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/05/22, located in the resident's EMR under the MDS tab indicated the facility assessed R118 to have a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident was severely cognitively impaired. The MDS also indicated R118 required limited assistance and one person assistance with eating. Review of R118's Physician's Orders, located in the resident's EMR under the Orders tab revealed R118 was ordered a regular diet, dysphagia advanced texture, thin liquids consistency: like bite size. During an observation of the lunch meal on 12/12/22 at 12:16 PM, R118 was being assisted with eating while in his bed by Certified Nurse Assistant (CNA)5, who was standing beside him while assisting him eat. There was no chair noted in the room at this time. During an interview on 12/12/22 at 2:32 PM, CNA5 stated she should have been sitting down. She confirmed she had received education on how to assist residents with meals and sitting down was a part of the education. During an interview on 12/13/22 at 2:49 PM, the Director of Nursing (DON) stated the expectations for staff assisting residents with meals would be for staff to provide dignity to residents by sitting next to them to feed the residents.

Based on record review and interview, the facility failed to provide a completed Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) that identified charges that may not be paid for by Medicare so they could assume financial responsibility should they desire to continue skilled services in order to address liability for payment for two (2) of two (2) residents who were reviewed for Advanced Beneficiary Notice (ABN), (Resident #114 and #17). The resident sample size was 25. Findings include: Review of facility policy titled Form Instruction Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018) revealed Section D for Estimated Cost Section stated The skilled nursing facility (SNF) should enter an estimated total cost or a daily, per item, or per service cost estimate. SNFs must make a good faith effort to insert a reasonable cost estimate for the care. The lack of a cost estimate entry on the SNFABN or an amount that is different than the final actual cost charged to the beneficiary does not invalidate the SNFABN. If for some reason the SNF is unable to provide a good faith estimate of projected costs of care at the time of SNFABN delivery, the SNF should indicate in the cost estimate area that no cost estimate is available. Number 3 for Option Boxes stated, The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary. 1. Review of the Advanced Beneficiary Notice (ABN) for Resident #114 revealed an admission date of 4/27/21. The last covered day of Medicare Part A Services was listed as 5/9/21. The ABN stated, Beginning on 5/10/21, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The identified care was listed as, Therapy/Skilled Nursing. The Reason Medicare May Not Pay was listed as Goals met. The estimated cost for these services if Resident #114 had to pay out of pocket was listed as, Monthly Income determined by Medicaid. This form did not list an amount that Resident #114 would have to pay out of pocket if Medicare did not cover skilled services beginning 5/10/21. The section on the ABN for Options, listed three (3) options to choose from: Option 1. I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the direction on the MSN. Option 2. I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Option 3. I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. These options are blank. The facility did not ensure Resident #114 chose an option. The ABN was signed by Resident #114 on 5/7/21. 2. Review of the Advanced Beneficiary Notice (ABN) for Resident #17 revealed an admission date of 11/19/2020. The last covered day of Medicare Part A Services was listed as 12/20/2020. The ABN stated, Beginning on 12/21/2020, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The identified care was listed as, Therapy/Skilled Nursing. The Reason Medicare May Not Pay was listed as Therapy Goals met. The estimated cost for these services if Resident #17 had to pay out of pocket was listed as, Determined by Medicaid monthly. This form did not list an amount that Resident #17 would have to pay out of pocket if Medicare did not cover skilled services beginning 12/21/2020. The section on the ABN for Options listed three (3) options to choose from: Option 1. I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the direction on the MSN. Option 2. I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Option 3. I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. These options are blank. The facility did not ensure Resident #17's Responsible Party (RP) chose an option. The ABN was unsigned. A note entered by the Business Office Manager (BOM) on 12/27/2020 stated, spoke with Responsible Party (RP) on 12/17/2020 at 9:36 a.m. RP would like for (Resident #17) to remain in the facility long term. Aware of appeal rights and last covered day. The ABN does not identify if the RP for Resident #17 wanted to appeal or not. On 5/19/21 at 3:30 p.m. during an interview with the BOM, he/she stated the cost of services was not identified because it would be determined by how much Medicaid money each resident received every month. He/she confirmed the ABN did not list an amount Resident #114 and Resident #17 would have to pay out of pocket if they chose to appeal and were denied or if they had chosen to pay privately for those services listed. He/she also confirmed the facility did not ensure Resident #114 and Resident #17's RP had chosen an option listed regarding the status of appeal. The BOM confirmed the options were left blank and the facility staff did not ensure the forms were completed as directed. The Administrator was present during the interview with the BOM on 5/19/21 at 3:30 p.m. and confirmed the ABN for Resident #114 and Resident #17 had not been completed as they should have been since the options were blank and a cost for services that were ending was not listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to follow policies and procedures for reporting abuse for one (1) of two (2) residents reviewed for abuse (Resident #60). Resident #60 reported an allegation of physical abuse to Certified Nursing Aide (CNA) #4 on 5/19/21 at 11:10 p.m. CNA #4 reported the allegation to Licensed Practical Nurse (LPN) #2. LPN #2 and CNA #4 failed to follow the facility's abuse policy as they did not report it to the Director of Nursing (DON), the facility Administrator and other officials. The allegation of physical abuse was reported again by Resident #60 to the Social Services Director (SSD) on 5/20/21 at 8:40 a.m. Findings include: Review of the facility policy titled Abuse Prevention Program revealed investigate and report any allegations of abuse within timeframes as required by federal requirements. Resident #60 was admitted on [DATE] with diagnoses including, but not limited to Other Sequelae of Cerebral Infarction, Other Reduced Mobility, Contracture of Muscle Left Upper Arm, Pain in Left Leg, Unilateral Primary Osteoarthritis Left Knee, and Primary Osteoarthritis Left Ankle and Foot. Review of Resident #60's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident had intact cognition. The resident is extensive assist for toilet use, personal hygiene, dressing, transfer and bed mobility. During an interview with Resident #60 on 5/20/21 at 8:47 a.m. S/he stated that CNA #1 who worked the 3:00 p.m. to 11:00 p.m. shift hit him/her with his/her call light at approximately 10:30 p.m. on 5/19/21. The resident stated that s/he clicked his/her call light for assistance because s/he had to use the toilet and waited one (1) hour and 45 minutes before CNA #1 came into his/her room. Resident #60 stated that CNA #1 came in and yelled at him/her for clicking his/her call light stating that s/he clicks the call light too much. CNA #1 then picked up the call light and hit the resident with it several times on his/her left arm and put the call light out of his/her reach. The resident stated that s/he notified CNA #4 on the 11:00 p.m. to 7:00 a.m. shift on 5/19/21 as soon as s/he came on his/her shift. The resident stated that there was no witness. During an interview on 5/20/21 at 9:25 a.m. with the Regional Nurse Consultant, s/he stated that s/he was notified by the SSD at approximately 8:45 a.m. on 5/20/21 of the allegation of abuse made by Resident #60. During an interview on 5/20/21 at 9:20 a.m. with the Administrator. The Administrator stated that s/he was notified by the Regional Nurse Consultant at approximately 8:47 a.m. on 5/20/21 of the allegation of abuse made by Resident #60. During a phone interview on 5/21/21 at 7:46 a.m. with CNA #4, s/he stated that s/he worked on 5/19/21 on the 11:00 p.m. to 7:00 a.m. shift and that Resident #60 was assigned to her/him. CNA #4 stated that approximately 10 minutes after his/her shift started s/he went down Resident #60's hall to check on her/his assigned residents. S/he stated that s/he entered Resident #60's room and the resident told her/him that s/he was hit by CNA #1 with the call light. CNA #4 stated that s/he immediately went and reported the allegation to LPN #2. During an interview on 5/21/21 at 11:10 a.m. with the DON, s/he stated that LPN #2 did not report the allegation of abuse to her/him. The DON stated that LPN #2 was responsible for reporting the allegation of abuse and performing an assessment of the reported injury. The DON stated that s/he has not been able to reach LPN #2 or CNA #1 for statements. During an interview on 5/21/21 at 3:10 p.m. with the Administrator. The Administrator stated that s/he expected staff to follow the facility abuse policy and report abuse immediately. Reporting is done based on the chain of command and it was his/her expectation that everyone was a reporter and reporting should be done immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy, the facility failed to report alleged violations of abuse immediately but no later than two (2) hours for one (1) of two (2) residents reviewed for abuse (Resident #60). Resident #60 reported an allegation of physical abuse to Certified Nursing Aide (CNA) #4 on 5/19/21 at 11:10 p.m. CNA #4 reported the allegation to Licensed Practical Nurse (LPN) #2. LPN #2 and CNA #4 did not report to the Director of Nursing (DON), the facility Administrator and other officials. The allegation of physical abuse was reported again by Resident #60 to the Social Services Director (SSD) on 5/20/21 at 8:40 a.m. Findings include: Resident #60 was admitted on [DATE] with diagnosis including but not limited to Other Sequelae of Cerebral Infarction, Other Reduced Mobility, Contracture of Muscle Left Upper Arm, Pain in Left Leg, Unilateral Primary Osteoarthritis Left Knee, and Primary Osteoarthritis Left Ankle and Foot. Review of Resident #60's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. The resident was extensive assist for toilet use, personal hygiene, dressing, transfer and bed mobility. During an observation of and interview with Resident #60 on 5/20/21 at 8:47 a.m. S/he stated that CNA #1 who worked 3:00 p.m. to 11:00 p.m. shift hit him/her with his/her call light at approximately 10:30 p.m. on 5/19/21. The resident stated that s/he clicked his/her call light for assistance because s/he had to use the toilet and waited one (1) hour and 45 minutes before CNA #1 came into his/her room. Resident #60 stated that CNA #1 came in and yelled at him/her for clicking his/her call light stating that s/he clicks the call light too much. CNA #1 then picked up the call light and hit the resident with it several times on his/her left arm and put the call light out of his/her reach. The resident stated that s/he notified CNA #4 on the 11:00 p.m. to 7:00 a.m. shift on 5/19/21 as soon as s/he came on shift. The resident stated that there was no witness. During an interview on 5/20/21 at 9:38 a.m. with the SSD, s/he stated that at approximately 8:40 a.m. s/he was walking down the hall when Resident #60 called her/him into his/her room. The resident reported the allegation of abuse to the SSD. The SSD stated that s/he went immediately to inform the Regional Nurse Manager. During an interview on 5/20/21 at 9:25 a.m. with the Regional Nurse Consultant, s/he stated that s/he was notified by the SSD at 8:45 a.m. of the allegation of abuse made by Resident #60. The Regional Nurse Consultant stated that CNA #1 was suspended, and an investigation was initiated. During an interview on 5/20/21 at 9:20 a.m. with the Administrator. The Administrator stated that s/he was notified by the Regional Nurse Consultant at approximately 8:47 a.m. of the allegation of abuse made by Resident #60. During a phone interview on 5/21/21 at 7:46 a.m. with CNA #4, s/he stated that s/he worked on 5/19/21 on the 11:00 p.m. to 7:00 a.m. shift and that Resident #60 was assigned to her/him. CNA #4 stated that approximately 10 minutes after her/his shift started s/he went down Resident #60's hall to check on her/his assigned residents. S/he stated that s/he entered Resident #60's room and the resident told her/him that s/he was hit by CNA #1 with the call light. CNA #4 stated that s/he immediately went and reported the allegation to LPN #2. During an interview on 5/20/21 at 9:40 a.m. with CNA #5, s/he stated that s/he arrived around 6:00 a.m. on 5/20/21. CNA #5 stated that s/he was assigned to Resident #60 and that the resident did not report the allegation to him/her. CNA #5 stated that when s/he relieved CNA #4, CNA #4 did not report the allegation of abuse to her/him during shift change. During an interview on 5/20/21 at 9:45 a.m. with LPN #3, s/he stated that s/he arrived at 7:00 a.m. on 5/20/21. LPN #3 stated that s/he did not receive an allegation of abuse from Resident #60 and it was not reported to her/him from LPN #2 during shift change. During an interview on 5/21/21 at 11:10 a.m. with the DON, s/he stated that LPN #2 did not report the allegation of abuse to her/him. The DON stated that LPN #2 was responsible for reporting the allegation of abuse and performing an assessment of the reported injury. The DON stated that s/he was not able to reach LPN #2 or CNA #1 for statements. An attempted interview was made on 5/20/21 at 12:42 p.m. and at 7:04 p.m. with CNA #1. CNA #1 did not answer, and a message was left. An attempted interview was made on 5/20/21 at 12:29 p.m. and 7:08 p.m. with LPN #2. LPN #2 did not answer, and a message was left.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of the facility policy, the facility failed to complete an accurate Minimum Data Set (MDS) Assessment for one (1) of 25 residents reviewed (Resident #41). Findings include: Review of the policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed the facility developed a comprehensive, person-centered care plan for each resident derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of Resident #41's clinical record revealed an admission date of 4/19/17 and the diagnoses included: Anoxic Brain Damage; Tracheostomy Status; Gastrostomy (g-tube) Status; Aphasia; and Cerebral Infarction. Review of Resident #41's Physician's Orders for May 2021 revealed trach care every shift with number (#) four (4) Disposable Trach and oxygen (O2) via trach at four (4) liters per minute (LPM). Review of Resident #41's Minimum Data Set (MDS) assessment dated [DATE] assessed the resident to have no speech but a Brief Interview for Mental Status (BIMS) score of zero (0). The resident required extensive assistance of two (2) staff for bed mobility, dressing, personal hygiene and toilet use. The resident required extensive assistance of one (1) person with locomotion and eating. The MDS further revealed the resident did not have a trach, did not use oxygen nor suctioning. Review of Resident #41's Care Area Assessment (CAA) for Communication dated 3/17/21 revealed the resident had diagnoses of Anoxic Brain damage and Aphasia. The resident was non-verbal and functionally immobile. Review of Resident #41's CAA for Feeding Tube dated 3/17/21 revealed the resident had a trach and did not receive anything by mouth. Observation with Licensed Practical Nurse (LPN) #4 on 5/18/19 at 2:15 p.m. revealed the resident lying in bed and did not respond to the staff. The resident had a trach with an oxygen mask placed over the trach and the oxygen was set at four (4) LPM. Further observation revealed a suction machine at the bedside. Observation on 5/20/21 at 9:33 a.m. during wound care revealed the Wound Care Nurse and the Nurse Scheduler turned and repositioned Resident #41 in the bed. Observation revealed the resident did not assist. Interview with the MDS Manager on 5/21/21 at 11:04 a.m. revealed they use the Certified Nurse Assistants' (CNAs) charting when completing Section G regarding activities of daily living (ADLs) on the MDS Assessment. They do not talk with the CNAs regarding the residents' ADL status. The MDS Manager confirmed Section G of the assessment was not correct. The resident did not assist with any ADLs. She also agreed Resident #41 did not talk so they could not have completed the BIMS for this resident. The MDS Manager further agreed the resident had a trach, and utilized oxygen and suctioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans for two (2) of 25 sampled residents (Resident #6 and #102). Resident #6 was observed on 5/18/21, 5/19/21, and 5/20/21 with oily build-up on his/her hair and scalp. Review of the Care Plan Progress Note dated 2/15/21 revealed the family requested that the resident's hair was washed more often. Review of Resident #6's comprehensive Care Plan with a last care plan review completed date of 3/1/21 revealed no care plan or interventions for washing Resident #6's hair. Further review of Resident #6's care plan revealed two (2) interventions that listed different sizes for the trach inner canula. Resident #102 developed Stage II pressure ulcers on the 2nd digit (index finger) of the left hand, 5th digit (small finger) on the left hand, 5th digit, and 4th digit (ring finger) on the right hand on 2/23/21. However, the facility failed review and revise the care plan with interventions to prevent pressure ulcers. Findings include: 1. Resident #6 was admitted on [DATE] with diagnoses including, but not limited to Contracture, Right Hand, Contracture, Left Hand, Muscle Weakness (Generalized), Other Lack of Coordination, Anoxic Brain Damage, Functional Quadriplegia, and Quadriplegia. Review of Resident #6's Annual Minimum data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 meaning the resident was severely impaired in cognition. The resident's Quarterly MDS assessment dated [DATE] revealed the resident was total dependance for bathing, extensive assistance for hygiene, no speech - absent of spoken words and is sometimes understood. Review of the resident's discharge assessment dated [DATE] revealed the resident is total dependance for bathing and hygiene. Review of Resident #6's Care Plan for ADL's (Activity of Daily Living) dated 9/2/2020 with a revision on 5/13/21 revealed a focus The resident has an ADL self-care performance deficit r/t (related to) anoxic brain damage, hx (history) cardiac arrest, dependent on oxygen with trach, impaired mobility, contracture in left and right hands, functional quadriplegia. With a goal of Resident needs will be anticipated and met through review period. With interventions that included bathing/showering: Provide sponge bath when a full bath or shower cannot be tolerated. Review of Resident #6's Care Plan Progress Note dated 2/25/21 revealed Care plan meeting held on this date with resident and IDT [Interdisciplinary Team]. RP [Resident Representative] was invited to attend and participated advance directives reviewed- DNR [Do Not Resituate] status remains in place. Reviewed current plan of care including medications and diet, RP requested we wash [her/his] hair more and that [her/his] nails be trimmed more. DC [Discharge] plan remains LTC [Long Term Care]. Will assist further as needed. Review of Resident #6's comprehensive Care Plan with a last care plan review completed date of 3/1/21 revealed no care plan or interventions for washing Resident #6's hair more frequently. During an observation on 5/18/21 at 9:53 a.m. Resident #6 was observed in his/her room, in bed, awake, with oily build up on the hair and scalp. During an observation on 5/19/21 at 11:52 a.m. Resident #6 was observed in his/her room, in bed, awake, with oily build up on the hair and scalp. During an interview on 5/20/21 at 9:47 a.m. with the Unit Manager (UM) on [NAME] unit/Medical Records Supervisor s/he stated Resident #6 has naturally fine and greasy hair. An observation of Resident #6 was made with the UM on [NAME] unit/Medical Records Supervisor, the resident had an oily build-up on his/her hair and scalp. When the UM on [NAME] unit/Medical Records Supervisor touched the resident's hair it stuck together. The UM on [NAME] unit/Medical Records Supervisor stated that the resident's hair was washed at her/his last bath and that this was natural. During an interview on 5/20/21 at 3:44 pm with Certified Nursing Aide (CNA), #2 s/he stated that the resident's hair was usually washed when they give showers, when they give bed baths, they do not wash the resident's hair every time. CNA #2 stated that Resident #6's hair was not washed during her/his bed bath on 5/18/21. CNA #2 stated that s/he could not recall if the resident's hair was washed on 5/14/21. CNA #2 stated that if a resident's hair was going to be washed it would be during the resident's bath or shower and was not a separate task done at a different time. Review of Resident #6's ADL-Bathing/Shower record for March 2021 revealed that bathing/showering was not documented for 3/2/21, 3/16/21, and 3/19/21. Documentation for 3/12/21 stated NA (Not applicable) The resident was hospitalized on [DATE] and readmitted on [DATE]. When the resident was discharged to the hospital on 3/20/21 the resident had not received a documented bathing/shower in 10 days. Review of Resident #6's ADL-Bathing/Shower record for April 2021 revealed Documentation for 4/2/21 and 4/6/21 stating NA which indicated that resident had not received bathing/shower in 9 days. During an interview on 5/20/21 at 11:15 a.m. with the Director of Nursing (DON), s/he stated that Resident #6 was scheduled for baths/showers every Tuesday and Friday on the 3-11 shift. The DON verified that blanks and NA on the ADL-Bathing/Shower record indicate the action was not documented as completed. During an interview on 5/20/21 at 8:34 a.m. with CNA #5, s/he stated that the CNAs provide care based on tasks listed in the CNA's electronic documentation system. S/he stated that a lot of the tasks are generic, and they had to just know the resident and what to fill out. S/he stated that they would go by the resident's care plan located in the care plan tab of the CNA's electronic documentation system. During an interview on 5/20/21 at 3:03 p.m. with MDS Coordinator, s/he stated that most of the care plan interventions were generic and where not tailored to the resident. S/he stated that interventions were put on the care plan based on orders, if there were no orders the care plan did not get updated until the next review. S/he stated that compliance checked for intervention implementation and evaluation was not conducted by the MDS Coordinators and s/he was not sure if nursing was doing any kind of check or audit. Review of Resident #6's Care Plan revealed a focus of The resident has a tracheostomy r/t [related to] respiratory failure, anoxic brain damage. She often unknowingly pulls out her trach when she has her hands resting on her neck. Date Initiated: 09/02/2020 Revision on: 05/13/2021 with a goal of The resident will have no s/sx [signs and symptoms] of infection through the review date. Date Initiated: 05/26/2020 Revision on: 05/30/2020 Target Date: 08/24/2021 The resident will have no abnormal drainage around trach site through the review date. Date Initiated: 05/26/2020 Revision on: 05/30/2020 Target Date: 08/24/2021. Interventions include: Trach inner canula uncuffed 6.0 Shiley. Date Initiated: 03/17/2021 Revision on: 03/30/2021, Tracheostomy care every shift and PRN using aseptic technique. Remove inner canula, clean with half strength H202 and sterile H20. Dry with sterile gauze and cotton swab. Re-insert inner canula, size 4 to lock. Clean outer cannula/stoma with sterile H20, rinse with sterile H20, pat dry with sterile gauze. May use split sterile gauze PRN. Every shift for trach care. Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB [head of bed] 45 degrees and stay with resident. Obtain medical help immediately. Date Initiated: 05/14/2020 Revision on: 05/13/2021. The review revealed that the two interventions listed different sizes for trach inner canula. Review of Resident #6's Physician's Orders dated 5/18/21 revealed an order for cuffed 6.0 Shiley inner cannula every shift related to Chronic Respiratory Failure with Hypoxia. 2. Resident #102 was admitted on [DATE] with diagnoses including, but not limited to, Rheumatoid Arthritis Unspecified, Contracture Left Hand, and Contracture Right Hand. Review of Resident #102's Provider note dated 2/23/21 revealed [S/he] has developed pressure injuries on the knuckles of L [left] hand as she uses them to help her move around in bed Con't [continue] to avoid pressure; Sure prep on open skin on knuckles on L [left] hand. Review of Resident #102's Provider note dated 3/9/21 .[S/he] developed pressure injuries on the knuckles of L/R hand as she uses them to help her move around in bed . Con't to avoid pressure; Sure prep on open skin on knuckles on L/R [left and right] hand. Resident of Resident #102's Skin and Wound evaluations from 2/12/21 through 3/16/21 revealed that Resident #102 developed pressure ulcers Stage II on the Left Hand, 2nd Digit (Index Finger), Left Hand, 5th Digit (Small Finger), and Right Hand, 4th Digit (Ring Finger). Review of Resident #102's Care Plan revealed Focus: The resident has an ADL self-care performance deficit r/t [related to] Severe RA [Rheumatoid Arthritis], bilateral hand contractures. Date Initiated: 02/12/2021. Revision on: 02/15/2021 with Goal: The resident will improve current level of function with feeding self through the review date. Resident will be able to: feed herself with limited assistance. Date Initiated: 02/15/2021. Revision on: 02/15/2021 Interventions included the following: Bathing/Showering: Assist x 1. Date Initiated: 02/22/2021. Transfer: Assist X 1. Date Initiated: 03/22/2021. Uses a wheelchair for mobility. Date Initiated: 03/24/2021. Meal Support: Cueing Date Initiated: 02/22/2021. Avoid scrubbing & pat dry sensitive skin. Date Initiated: 02/15/2021. Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 02/15/2021. Bathing/showering: Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 02/15/2021. Bed Mobility: The resident requires extensive assistance by 1 staff to turn and reposition in bed. Date Initiated: 02/15/2021. Revision on: 02/15/2021. Contractures: The resident has contractures of the (SPECIFY location of contracture). Provide skin care (SPECIFY FREQ) to keep clean and prevent skin breakdown. Date Initiated: 02/15/2021. Dressing: The resident requires extensive assistance by 1 staff to dress. Date Initiated: 02/15/2021. Revision on: 02/15/2021. Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 02/15/2021. Encourage the resident to use bell to call for assistance. Date Initiated: 02/15/2021. Praise all efforts at self care. Date Initiated: 02/15/2021. During an interview on 5/20/21 at 3:03 p.m. with MDS Coordinator, s/he verified that under the intervention for contractures in Resident #102's care plan it stated (SPECIFY location of contracture) and (SPECIFY FREQ). The MDS Coordinator stated that this should have been filled out and that s/he will correct the care plan and insert the missing information. The MDS Coordinator verified that the care plan was not reviewed and revised when Resident #102 developed pressure ulcers to left and right hands. Review of Resident #102's Care Plan revealed a focus for Risk for skin breakdown Resident is at risk for skin breakdown related to pain with an initiated date of 4/7/21. The goal stated, Resident will not have any areas of skin breakdown through the next review and was initiated on 4/7/21. Interventions included: If an ulcer develops notify MD [Medical Doctor] or designee, and responsible party. Date Initiated: 04/07/2021. Observe skin through daily care provisions. Date Initiated: 04/07/2021. Pressure reduction wheelchair cushion per order. Date Initiated: 04/07/2021. Provide daily preventative skin care Date Initiated: 04/07/2021, Provide incontinent care as indicated Date Initiated: 04/07/2021, RD to review and make nutritional recommendations as indicated. Date Initiated: 04/07/2021. Refer to podiatrist as needed for preventative foot care. Date Initiated: 04/07/2021. Turn and re-position as indicated. Date Initiated: 04/07/2021. Weekly nursing assessment to observe for skin breakdown. Date Initiated: 04/07/2021. Weigh per order/per facility policy. Date Initiated: 04/07/2021. During an interview on 5/21/21 at 3:39 p.m. CNA #6 stated that there was no restorative program. CNA #6 stated that s/he would refer to the care plan for services s/he had to provide to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (2) of 25 sampled residents (Resident #42 and #60). Resident #42 had a medical doctor's referral that the facility failed to follow up with and the facility failed to follow up on Resident #42's eyeglasses. Resident #60 was discharged to the hospital on 4/24/21 and readmitted on [DATE]. Resident #60's physician orders were not discontinued from the residents electronic medical record when the resident was discharged to the hospital per the facility procedure. When Resident #60 was readmitted to the facility on [DATE], orders from before the resident's hospitalization were still in the electronic medical record. The Nurse Practitioner (NP) reviewed the hospital discharge summary and the electronic medical record on 5/3/21, decisions were made regarding the resident's medication list. On 5/13/21 orders from before the resident's hospitalization were discontinued in the electronic system, but this was done after the NP had reviewed the orders. Findings include: 1. Resident #60 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus without Complications. Review of Resident #60's Physician's Orders revealed metformin HCl Tablet 1000 MG [milligrams] Give 1 tablet by mouth two times a day related to Type 2 Diabetes Mellitus without Complications (E11.9) start date 3/29/2021 discontinued date 5/13/2021 Novolog Solution (Insulin Aspart) Inject as per sliding scale: if 0 - 250 = 0 units Call MD [Medical Doctor] if BS [blood sugar] <60; 251 - 300 = 2 units; 301 - 350 = 3 units; 351 -400 = 4 units; 401 - 450 = 5units; 451 - 500 = 6 units Call MD if BS >500, subcutaneously two times a day for DM [Diabetes Mellitus] started on 3/4/21 discontinued dated 5/13/21. Review of Resident #60's Hospital Discharge summary dated [DATE] revealed that the resident was hospitalized from [DATE] to 5/1/21 for pneumonia. Further review revealed Type II DM: At home, patient takes 1000 mg metformin BID [twice a day] and LDSSI [low-dose sliding scale insulin] for diabetes management. While in the hospital, [s/he] was continued on LDSSI, which was increased to MDSSI [moderate dose sliding scale insulin] at mealtime due to rising glucose. [S/he] will continue [his/her] home regimen at discharge. During an interview on 5/19/21 at 1:45 p.m. with Physician's Assistant (PA) #1, s/he stated that providers do not input orders in the electronic records, orders are written on sheets and the nursing staff would input in the record. PA #1 stated that there had been times when orders are imputed wrong, s/he did not have control over what was put in the system. PA #1 stated that s/he wished the providers could input the order to decrease discrepancies. PA #1 stated s/he was not the provider that did Resident #60's re-admission, but for a re-admission from a hospital the providers went by what was in the electronic record at the time of review and the hospital discharge summary. S/he stated the resident should be on his/her metformin. PA #1 stated that when a resident is discharged to the hospital all orders are discontinued. New orders would be placed when the resident returned. The orders were not discontinued when Resident #60 went to the hospital instead they were discontinued 10 days after the provider's review. PA #1 stated QA (quality assurance) would need to look into the delay. PA #1 stated that in the current system there was nothing that flagged that a medication had been changed, s/he looked at orders every time s/he saw a resident and at least once a week, but nothing should change if the provider did not order the change. During an interview on 5/19/21 at 2:27 p.m. with the Director of Nursing (DON), s/he stated that all orders are discontinued when a resident is discharged to the hospital. The DON stated s/he would need to look into Resident #60's chart. At 3:48 p.m. the DON stated that Resident #60 went to the hospital on 4/24/21 and returned on 5/1/21, staff did not discontinue medication from the electronic record when the resident was sent to the hospital. The DON verified that the medication was discontinued on 5/13/21 after the provider's review. The DON stated that on 5/13/21 medications where not there from the pharmacy, when the pharmacy was contacted, they stated that they did not have an order, staff then went in and discontinued the medication. The DON also stated that staff entered the medication from the hospital discharge summary, the DON stated that the hospital set us up for failure because they did not list metformin in the discharge medications list, instead it was listed in the body of the discharge summary. The DON stated that the metformin was missed and should have been added. At 4:00 p.m. the Assistant Director of Nursing (ADON) stated that s/he talked with PA #1 and PA #1 entered an order for metformin. Record review revealed an order for metformin HCl Tablet 1000 MG Give 1 tablet by mouth two times a day related to Type 2 Diabetes Mellitus without Complications start date 5/19/2021. During a phone interview on 5/21/21 at 2:47 p.m. with the Medical Director. S/he stated that providers would look at the discharge summary and electronic health record of a resident when they were readmitted . What s/he recalled is that the staff did not discontinue the resident's orders when Resident #60 was discharged to the hospital. The Medical Director stated when the NP reviewed the electronic record and the hospital discharge summary s/he verified that the resident's orders were correct at the time, then staff went in after the NP and discontinued orders. The Medical Director stated that s/he spoke with PA #1 and s/he reordered Resident #60's metformin but decided not to reorder the blood sugar checks and sliding scale based on his/her assessment of the resident. 2. Review of Resident #42's clinical record revealed an admission date of 10/10/19 and the diagnoses included: Transient Cerebral Ischemic Attack; Specified Disorders of Teeth and Supporting Structures; Maxillary Fracture, Right Side, Subsequent Encounter for Fracture with Routine Healing; and Suicide Attempt with Firearm Discharge. Review of Resident #42's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, with a score of 13 to 15 indicating intact cognition. The MDS revealed the resident wore glasses and had no pain. Review of Resident #42's Care Plan dated 3/25/21 revealed the resident had an eye deformity/impaired vision with the interventions for staff to provide glasses and refer for an eye consult as indicated. Review of Resident #42's Care Plan dated 3/25/21 revealed the resident was at risk for dental complications related to abnormal mouth tissues, difficulty providing mouth care related to limited range of motion in the mouth related to gun-shot wound to the face through the mouth, discomfort or difficulty chewing, and mouth or facial pain related to scar tissue in mouth and face. The intervention included to refer for dental consult as needed. Review of the Social Service Note dated 12/22/2020 at 2:06 p.m. revealed the resident wanted to reschedule the maxillofacial appointment that was cancelled earlier in the year due to COVID. Nursing to follow up. Review of the Report of Consultation dated 12/4/19 revealed the right upper canine was mobile and the recommendation for a referral to oral surgery. Review of Resident #42's Eye Care Chart Note dated 2/23/21 at 2:20 p.m. revealed the resident had blurry vision and the doctor provided a prescription for new glasses. Observation of Resident #42 on 5/18/21 at 12:30 p.m. and on 5/19/21 at 9:44 a.m. revealed the resident did not wear his/her glasses. Interview with Resident #42 on 5/18/21 at 2:15 p.m. revealed he/she saw the eye doctor in February and the doctor provided a new lens prescription for the left eye to the facility. The resident gave two (2) pairs of glasses to the Social Worker to have the new lenses installed in them. Today the Social Services Assistant gave him/her back one (1) pair of the glasses (without the new lenses in them). The resident stated he/she had not received the other pair of glasses with the new lenses yet. Resident #42 also stated he/she was frustrated because he/she was supposed to have surgery on his/her mouth a long time ago and does not know when it will be done. Interview with the Social Services Assistant on 5/18/21 at 2:18 p.m. revealed Resident #42 just saw the eye doctor two (2) weeks ago and the new lenses had not come in yet. Interview with the Social Worker on 5/18/21 at 2:24 p.m. revealed the facility had taken the glasses to an eye glass store but the resident stated he/she could not afford the new glasses. S/he stated s/he needed to call the family about the cost of the glasses but had not as of yet. The Social Worker confirmed the facility had received the new prescription in February. The Social Worker stated after the eye doctor came to the facility, s/he would print off the progress notes and place them on the doctor's clip board, where the primary physician would review and approve them. Regarding the oral surgery appointment, s/he did not realize the process for making doctor appointments and told the Unit Manager the resident needed an oral surgery appointment made. S/he did not realize that it was part of his/her job to make the appointment. Interview with Unit Manager (UM) #2 on 5/18/21 at 2:29 p.m. revealed s/he stated the Social Worker did not tell him/her that Resident #42 needed an oral surgery appointment, maybe s/he told the [NAME] Clerk. Interview with [NAME] Clerk #1 on 5/18/21 at 2:47 p.m. revealed Resident #42 had an oral surgery appointment made for 8/3/21. S/he further stated the appointment was made last month. On 5/19/21 at 9:44 a.m. during observation of medication administration, Resident #42 again asked the surveyor about his/her glasses. The surveyor immediately went to get UM #2. UM #2 told Resident #42 that the eye doctor he/she saw was where his/her glasses would come from and s/he would call to see why they had not sent him/her his/her new glasses. The glasses had been ordered but just not came in yet. UM #2 continued to tell Resident #42 it was the eye doctor's fault for Resident #42 to not have his/her glasses. The resident's insurance would cover the cost of the glasses. Resident #42 then stated, I am so frustrated here with the incompetency here. Interview with UM #1 on 5/19/21 at 1:00 p.m. revealed the facility had called the eye glass shop and the facility was going to pay the one hundred dollars ($100.00) for the new eye glass lenses. The shop was going to send the glasses off right away so he/she could get his/her new lenses. UM #1 further stated the children did not have anything to do with Resident #42, so s/he did not call them regarding the glasses. Review of Resident #42's clinical record revealed multiple entries of the children talking with the facility about the resident, sending him clothes and a new phone. Review of the policy titled Assistive Devices and Equipment dated 1/2020 revealed the facility provided the resident with assistance in locating available resources to obtain assistive devices that were not provided by the facility, including glasses. Review of the Job Description: Social Services Director dated 3/2017 revealed the essential duties included: Assist in securing appropriate prosthetics and assistive devices, assist in making outpatient appointments as ordered, and schedule on-site ancillary resident services to include optometry, podiatry, dentistry and psychiatric services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure residents with pressure ulcers received necessary care and services to promote healing and prevent new ulcers from developing for two (2) of three (3) residents reviewed for pressure ulcers (Resident #102 and #15). 1.The facility failed to provide effective interventions for the prevention of multiple pressure ulcers for Resident #102. 2. The facility failed to provide interventions to prevent the development of a Stage two (II) pressure ulcer to Resident #15's foot, who was being treated for a Stage two (II) pressure ulcer to the coccyx. Findings include: Review of the policy titled, Pressure Ulcers/Skin Breakdown-Clinical protocol, dated 4/2018, revealed the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure(s). 1. Resident #102 was admitted on [DATE] with diagnoses including, but not limited to, Rheumatoid Arthritis Unspecified, Contracture Left Hand, and Contracture Right Hand. During an interview on 5/18/21 at 10:10 a.m. with Resident #102, s/he stated both hands were contracted, and s/he had not been seen by therapy. The resident stated that s/he used her/his hands to reposition her/himself in bed and other daily activities. Resident #102 stated that while at the facility s/he developed wounds on both of her/his hands from using them. Review of Resident #102's Provider Note dated 2/15/21 revealed .[female/male] with a h/o [history of] severe RA [Rheumatoid Arthritis] who was admitted to hospital with CHF [Congestive Heart Failure] exacerbation, Afib [Atrial fibrillation ] with RVR [rapid ventricular response], dilated cardioypay Pt [patient] was clinically stable and transferred to [another facility] for further rehab, strengthening and conditioning, Pt continues to have pain and difficulty completing ADLs [activities if daily living] due to progression of RA affecting [her/his] hands. Further review revealed Rehabilitation plan: PT [physical therapy], OT [occupational therapy], ST [speech therapy] screen, evaluate and treat as indicated. Review of Resident #102's Physical Therapy Plan of Care (Evaluation Only) dated 2/14/21 revealed under Reason For Referral: it stated .Patient presents with complaints of weakness, pain, decreased endurance and mobility which began to interfere with all functional mobility and pt has become more debilitated due to severe RA. Pt was requiring total assist for ADL's prior to hospitalization and only short distance gait performed. Under Therapy Necessity it stated Therapy necessary for execution of HEP [Home Exercise Program] in order to encourage strength gains for stability and transfer ability and gait tasks. Without therapy patient at risk for falls, decline in functional mobility. Under Discharge Plans it stated d/c [discharge] tbd [to be determined], possible LTC [long term care] vs [verse] home with hospice the evaluation was signed by the Physician with a certification date of 2/14/21 to 3/13/21. Review of Resident #102's medical record revealed no additional documented physical therapy (PT) and no documented evaluation for occupational therapy (OT). During an interview on 5/20/21 at 2:41 p.m. with the Director of Therapy (DOT). S/he stated that Resident #102 was admitted on [DATE], therapy did not know if the resident would be home health or stay long term care. When they found out the resident was long term care PT did an eval on 2/14/21. A hospice referral was done on 2/16/21 and that is why PT only did an eval. The DOT stated that Resident #102 went to the hospital several times and therapy will screen the resident when s/he returns from the hospital, but they do not do an evaluation, there is no documentation of the screenings. The DOT stated that a referral for therapy was not sent to evaluate the resident for positioning or ADL's. The DOT stated that s/he was not aware of Resident #102's pressure injuries to L/R knuckles from positioning until the surveyor asked her/him about them on 5/20/21. The DOT stated that Resident #102 had been on and off hospice. Record review of Resident #102's medical record revealed that a hospice evaluation was done on 2/19/21. Social Service Note dated 2/23/21 revealed Received notification from [Name] Hospice rep [representative] that patient is not appropriate for hospice at this time. Will assist further as needed. Resident #102 was admitted to hospice on 4/15/21 and discharge from hospice on 5/5/21. Review of Resident #102's Progress Note dated 2/19/21 revealed Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: callouses on knuckles have opened up. Patient has severely contracted hands and uses [her/his] knuckles for repositioning and other daily functions. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: paint with skin prep for wound care and protection. Review of Resident #102's Provider Note dated 2/23/21 revealed [S/he] has developed pressure injuries on the knuckles of Left hand as s/he uses them to help her/him move around in bed Review of Resident #102's Provider Note dated 3/9/21 revealed .[S/he] developed pressure injuries on the knuckles of L/R hand as she uses them to help her move around in bed . Resident of Resident #102's Skin and Wound evaluations for the resident Left Hand, 2nd Digit (Index Finger) revealed: 2/18/21: Left Hand, 2nd Digit (Index Finger) pressure Stage II no measurements. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 2/23/21: Pressure stage II Left Hand, 2nd Digit (Index Finger) 0.8 cm2 x 1.4 cm x 0.9 cm. Under notifications the box for Practitioner Notified was checked as completed. The boxes for Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/2/21: Pressure stage II Left Hand, 2nd Digit (Index Finger) 0.7 cm2 x 1.2 cm x 0.9 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/9/21: Pressure stage II Left Hand, 2nd Digit (Index Finger) 0.3 cm2 x 0.9 cm x 0.4 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/16/21: Pressure stage II Left Hand, 2nd Digit (Index Finger) 1.0 cm2 x 1.3 cm x 1.0 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. Resident of Resident #102's Skin and Wound Evaluations for the residents Left Hand, 5th Digit (Small Finger) revealed: 2/18/21: Pressure stage II Left Hand, 5th Digit (Small Finger) no measurements. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 2/23/21: Pressure stage II Left Hand, 5th Digit (Small Finger) 0.5 cm2 x 1.0 cm x 0.6 cm. Under notifications the box for Practitioner Notified was checked as completed. The boxes for Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/2/21: Pressure stage II Left Hand, 5th Digit (Small Finger) 0.2 cm2 x 0.5 cm x 0.5 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/9/21: Pressure stage II Left Hand, 5th Digit (Small Finger) 0.4 cm2 x 0.8 cm x 0.7 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/16/21: Pressure stage II Left Hand, 5th Digit (Small Finger) 0.2 cm2 x 0.8 cm x 0.4 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. Resident of Resident #102's Skin and Wound Evaluations for the residents Right Hand, 4th Digit (Ring Finger) revealed: 2/18/21: Pressure stage II Right Hand, 4th Digit (Ring Finger) no measurements. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 2/23/21: Pressure stage II Right Hand, 4th Digit (Ring Finger) < 0.1 cm2 x 0.4 cm x 0.2 cm. Under notifications the box for Practitioner Notified was checked as completed. The boxes for Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/2/21: Pressure stage II Right Hand, 4th Digit (Ring Finger) 0.6 cm2 x 1.0 cm x 0.9 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/9/21: Pressure stage II Right Hand, 4th Digit (Ring Finger) 0.3 cm2 x 0.8 cm x 0.6 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/16/21: Pressure stage II Right Hand, 4th Digit (Ring Finger) 0.7 cm2 x 1.1 cm x 0.8 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. 3/23/21: Pressure stage II Right Hand, 4th Digit (Ring Finger) 0.5 cm2 x 1.0 cm x 0.8 cm. Under notifications the boxes for Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) Notified were not checked as completed. Review of Resident #102's Progress Notes from 2/12/21 through 5/19/21 revealed the resident had a history of refusing medication, there was no documentation of the resident refusing PT, OT, or ADL care. During an interview on 5/21/21 at 3:39 p.m. CNA #6, s/he stated that there is no restorative program. CNA #6 stated that s/he will refer to the care plan for services s/he had to provide to the resident. During an interview on 5/19/21 at 1:45 p.m. with Physician Assistant (PA)#1, s/he stated that Resident #102 has a severe case of Rheumatoid Arthritis. The PA stated that the resident would be a good candidate for PT if her/his pain was under control. Continued interview revealed due to the disease process the resident could get some mobility back in her/his hands, but her/his lower body would benefit more from the PT. 2. Review of Resident #15's clinical record revealed an admission date of 7/16/19 and a readmission date of 6/24/2020 and the diagnoses included: Dementia with Behavioral Disturbance; Epilepsy; Anxiety Disorder; Diabetes; and Abnormal Posture. Review of Resident #15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four (4) with a score of zero (0) to eight (8) indicating severe cognition impairment. The MDS revealed the resident required extensive assistance of one (1) staff for bed mobility, dressing, eating, toilet use and personal hygiene. The MDS revealed the resident required total assistance of two (2) staff with transfers and bathing and required total staff assistance of one (1) staff with locomotion and did not ambulate. The resident was frequently incontinent of bowel and bladder and had one (1) Stage two (II) pressure ulcer and had a pressure relieving device in the chair and pressure relieving mattress on the bed. Resident #15's MDS revealed the resident had a significant weight gain. Review of Resident #15's Care Plan dated 3/3/21 listed the interventions for Sacral Pressure Ulcers to include: supplements as ordered for wound healing and Wound Nurse to follow as indicated. Review of the Care Plan for Resident #15 revealed he/she was at Risk for Skin Breakdown, and the resident has discoloration to feet with the initiated date of 7/17/19. The listed interventions were as follows: 7/17/19 - if an ulcer developed notify the wound nurse, family and physician, observe skin through daily care provisions, pressure reduction wheelchair cushion per order, provide daily preventative skin care, provide incontinent care as indicated, Registered Dietician (RD) to review and make nutritional recommendations as indicated, refer to podiatrist as needed for preventative foot care, turn and re-position as indicated, weekly nursing assessment to observe for skin breakdown, and use pillow to offload pressure from heels as indicated. 11/23/2020 - apply treatment to bilateral feet as ordered, supplements as ordered for wound healing and treatment per order and Wound Nurse to follow as indicated. Review of Resident #15's Physician's Orders revealed an order to elevate bilateral extremities while in bed and chair every shift for edema with the ordered date, 1/28/2020. Review of the orders revealed an order for Prostat Sugar Free 30 cubic centimeters (cc) two times a day as a dietary supplement for wound care ordered on 9/4/2020. Further review of the Physician's Order dated 11/17/2020 revealed the resident was admitted to hospice for Cerebrovascular Disease with Vascular Dementia. Apply skin prep to all discoloration on bilateral feet every shift with the start date of 11/21/2020 and treatment to pressure ulcer on the coccyx revised on 5/3/21. Review of the Braden Scale dated 5/12/21 scored Resident #15 at a 13 with a score of 13 to 14 placing the resident at a moderate risk for the development of pressure ulcers. Review of the Nurse's Note dated 5/10/21 at 3:34 p.m. revealed the resident required total care with activities of daily living (ADLs), was out of bed to the geriatric chair (g-chair) (chair that reclines and legs/feet can be elevated). Observation of Resident #15 on 5/19/21 at 12:06 p.m., 12:39 p.m. and 12:52 p.m., revealed the resident sat in a g-chair with feet hanging down unsupported and no pressure relieving device in the chair. Observation on 5/20/21 at 10:44 a.m. revealed the resident laid in bed on his/her left side and the feet not elevated off the bed. Observation on 5/20/21 beginning at 11:13 a.m. with the Wound Care Nurse and the Nurse Staffing Coordinator revealed they provided wound care to the pressure ulcer on the coccyx. At the end of the treatment, the surveyor asked to do a skin check of the feet. Observation at that time revealed the resident had decreased range of motion of the lower extremities and the feet laid directly on top of each other and not elevated off the bed or offloaded. Further observation when staff removed the top foot off the bottom foot revealed an open area to the top/side of the right foot. The Wound Care Nurse stated the area was new and he/she would talk with the provider for a treatment order since it was an open area. Staff did not place a protective dressing and did not provide pressure relief to the feet prior to covering the resident up with blankets. Review of the Skin and Wound Evaluation dated 5/21/21 revealed the Wound Care Nurse measured the In-House Acquired and New Stage II pressure ulcer as 1.7 centimeters (cm) by 1.5 cm. on the upper side of the right foot. Interview with Licensed Practical Nurse (LPN) #5 on 5/20/21 at 10:42 a.m. revealed for skin prevention and care, staff use a wedge cushion to help with positioning, turn and reposition every two (2) hours, apply skin prep on feet, did not use pressure relieving heel protectors and the resident required total assistance with ADLs. Interview with Certified Nursing Aide (CNA) #7 on 5/20/21 at 10:56 a.m. revealed the staff should turn and reposition the resident every two (2) hours but sometimes before three (3) hours, use pillows between the legs, wedge for positioning but no heel protection. Interview with the Director of Nursing (DON) on 5/21/21 at 9:18 a.m. regarding the Wound Care Program revealed if the resident was assessed to be at risk for skin breakdown, the facility would initiate a turn and repositioning program and check the skin regularly. The facility looked at the root cause analysis as to why they developed a pressure ulcer and also talked about each resident in the Monday through Friday Stand-up Meeting. The DON confirmed the facility should have initiated interventions to prevent the development of the pressure ulcer to the foot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of facility policy, the facility failed to provide interventions as planned for the presence of a significant weight loss for one (1) of three (3) residents reviewed for weight loss (Resident #31). Resident #31 had a significant weight loss of 20.45 % (percent) between 2/25/21 and 5/19/21. However, staff were not assisting the resident with eating at meals per observations, not providing the resident's food likes, and they were inaccurately documenting the percentage of meal consumption. Findings include: Review of the facility's policy titled, Activities of Daily Living, Supporting, dated 3/2018 revealed the residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of Resident #31's clinical record revealed an admission date of 2/5/21 and a readmission date of 2/24/21 and the diagnoses included: Hemiplegia; Dysphagia; Mood Disorder; Anxiety Disorder; Anorexia; and Developmental Disorder of Scholastic Skills. Review of Resident #31's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of five (5) with a score of zero (0) to eight (8) indicated severe cognitive impairment. The MDS revealed the resident required extensive assistance of one (1) staff with eating. The resident weighed 122 pounds, had the presence of weight loss and not on a physician prescribed weight loss program. The MDS revealed the resident did not have dental issues and held food in his/her mouth. Review of Resident #31's Care Area Assessment (CAA) for Nutrition dated 3/2/21 revealed the resident had a significant weight loss related to unknown etiology of greater than five (5) percent (%) in less than 30 days. Review of the Dietary Interview/Pre-Screen assessment dated [DATE] revealed Resident #31 wanted coffee at breakfast and lemonade at lunch and dinner. The resident liked snacks and yogurt and disliked fried, scrambled, and poached eggs and did not like fish or grits. Review of the Weight List revealed: 2/25/21 - 122.2 lbs. (day after readmission) 3/1/21 - 113 lbs. 4/9/21 - 95.6 lbs. 4/15/21 - 96.2 lbs. 4/22/21 - 96 lbs. 4/28/21 - 101.8 lbs. 5/5/21 - 96.6 lbs. 5/7/21 - 97.4 lbs. 5/12/21 - 97.4 lbs. 5/19/21 - 97.2 lbs. Consisting of a 25-pound weight loss or 20.45% weight loss in approximately three (3) months. Review of Resident #31's Care Plan dated 3/14/21 listed the interventions: 2/24/21: Resident needed assistance of one (1) staff to eat and drink. 2/25/21: Diet and liquids per physician order, regular diet and texture, thin liquid consistency and finger foods, Dietician to review as indicated for dietary recommendations, exclude food intolerance and allergies from meals, honor religious food preferences, snack at bedtime related to Diabetes, labs per order and notify physician of results, refer to speech therapy as indicated for difficulty with eating, snacks per preference/request, and supplements per order and offer decreased calories in meals (for a resident losing weight). 3/11/21 - Occupational and Speech Therapy to evaluate and treat as ordered. Review of Resident #31's Physician's Orders included: 2/25/21 - regular diet of regular texture and thin liquids. 3/19/21 - Ensure Plus, one (1) can, three (3) times a day. 4/15/21 - Prostat 30 cubic centimeters (cc) three times a day for wound healing. 4/16/21 - Mighty Shake with meals. 5/7/21 - Magic Cup, one (1) time a day with lunch. 5/12/21 - Weigh every Wednesday. Review of the Nutritional Risk assessment dated [DATE] revealed the plan for: Alert physician of significant weight loss, offer finger foods, offer Ensure one (1) can three (3) times a day between meals and alert the Registered Dietician (RD) if the resident did not like it, consider checking Basic Metabolic Panel to assess hydration status and RD to follow-up as needed and quarterly. Review of the Basic Metabolic Panel dated 3/22/21 revealed all values were within normal range. Review of the RD Note dated 4/15/21 revealed the plan for a psych evaluation for possible depression impacting appetite, consider artificial nutrition by tube related to significant weight loss, alert physician and power of attorney of significant weight loss, weekly weights times four (4) weeks, offer Mighty Shake three (3) times a day with meals and RD to follow-up as needed and quarterly. Review of the RD Note dated 5/6/21 revealed he/she discussed with the resident his/her desires for artificial nutrition by tube and the resident was very clear he/she did not want that. The goal was to deter weight loss as able. Observation on 5/18/21 at 1:42 p.m. revealed Resident #31 sat in a high back wheelchair in his/her room with a Mighty Shake and frozen supplement on the overbed table in front of him/her. No staff were present in the room to assist the resident. Observation on 5/19/21 at 11:58 a.m. revealed Resident #31 sat in a wheelchair in his/her room and Certified Nurse Assistant (CNA) was present in the room. The meal consisted of egg salad sandwich, pasta salad, lettuce salad, cookie, Magic Cup, health shake and tea. The staff did not provide him/her lemonade as per his/her choice. Further observation revealed the CNA's cell phone went off and then the CNA was noted to be texting on the cell phone while sitting in the resident's room and not assisting the resident with his/her lunch meal. Observation on 5/19/21 at 12:08 p.m. revealed staff removed the lunch tray from the room and the resident ate one (1) bite of the egg salad sandwich, 75 percent (%) of the pasta salad, four (4) ounces (oz) of Mighty Shake, one (1) bite of Magic Cup, and 25% of lettuce salad. Review of the Meal Intake in the CNA's computer documentation revealed staff documented the resident ate 76 to 100 percent of the noon meal on this date. Observation on 5/20/21 at 8:39 a.m. revealed the resident laid in bed with the breakfast tray in front of him or her, not eating and no staff were present. The breakfast meal consisted of Health Shake, hot cereal, toast, orange juice, and scrambled egg casserole. The staff did not provide coffee as per the resident's choice but provided scrambled egg casserole against the resident's choice. Observation on 5/20/21 at 8:42 a.m. revealed staff removed the tray from the room and the resident had only consumed the orange juice and the Health Shake. Review of the Diet Slip at that time revealed the resident received a regular diet, finger foods, Magic cup with lunch, eight (8) ounces of coffee or tea. Review of the Meal Intake in the CNA's computer documentation revealed staff documented the resident ate zero (0) to 25 percent of the breakfast meal on this date. Observation on 5/20/21 at 12:04 p.m. revealed the uncovered lunch tray on the overbed table, the resident was not eating, and no staff were present in the room. Observation on 5/20/21 at 12:21 p.m. (17 minutes after meal was observed uncovered) revealed CNA #7 entered the room and stood by the resident's bed but did not provide assistance with eating. Observation on 5/20/21 at 12:26 p.m. revealed staff removed the lunch tray from the room. Further observation at that time revealed the resident drank two (2) ounces of the Mighty Shake, glass of ice tea, ate 50% of the piece of cake, but did not eat any of the country fried steak with cream gravy, mashed potatoes, peas, dinner roll, or the frozen nutritional treat. Staff did not provide the resident's choice for lemonade. Review of the Meal Intake in the CNA's computer documentation revealed staff documented the resident ate 26 to 50 percent of the noon meal on this date. Interview with Licensed Practical Nurse (LPN) #5 on 5/20/21 at 10:46 a.m. revealed Resident #31 required total assistance with eating. The resident also received a Magic cup which they would document the percentage eaten. The resident also received Ensure and a Mighty Shake which they did not document the amount consumed, but only placed a check mark indicating they gave the supplement but not how much was consumed. Interview with CNA #7 on 5/20/21 at 10:58 a.m. revealed Resident #31 required total assistance with meals. Interview with the Dietary Manager on 5/20/21 at 12:34 p.m. confirmed the resident's Dietary Slip did not include the lemonade the resident requested at lunch and dinner. He/she further stated the staff on the unit were responsible for providing the coffee to the resident. Interview with the RD on 5/20/21 at 12:40 p.m. revealed he/she had tried all the interventions he/she had to get Resident #31 to gain weight. The RD also stated the resident did not have a responsible party or family, so he/she had talked with the resident about getting a percutaneous tube and the resident did not want that. Further interview with the RD revealed the RD did not usually watch meals and was unaware the resident's intake and the documented meal percentage did not match or the staff did not consistently document the percentage of the supplements consumed. Interview with the Director of Nursing (DON) on 5/21/21 at 9:18 a.m. revealed meal consumption documentation consisted of the food eaten and the liquids consumed at meals was documented separate from the food consumed. The DON also stated the staff documented the amount of all supplements consumed. The DON stated the nutrition program consisted of the RD monitoring the weights monthly unless a more frequent time period was ordered. The computer system would provide an alert if the resident had a significant weight loss. The RD reviewed the meal intakes and tailored the program for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure the physician responded in a timely manner to pharmacy recommendations for identified irregularities for two (2) (Resident #22 and #64) of five (5) resident medication regiment reviewed. Findings include: Review of the facility policy titled Medication Regimen Review (MRR) with an effective date of 11/28/16 stated, 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. 1. Review of Resident #22's face sheet in the medical record revealed he/she was admitted on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction and Hypertension (HTN). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 11 of 15, indicating mild cognitive impairment. Review of admission Orders for Resident #22 dated 2/15/21 revealed an order for Aspirin Tablet Chewable-Give one (1) tablet by mouth one (1) time a day for HTN. A change order dated 3/31/21 was entered for Aspirin 81 milligrams (mg) by mouth one (1) time a day for CVA (Cerebrovascular Accident) was noted on the current Physician's Orders for the month of May 2021. Review of the Pharmacy Consultation Report dated 2/17/21 noted a recommendation to Please update the Aspirin order to include the strength 81 mg. A review of a second Pharmacy Consultation Report dated 3/17/21, noted a recommendation to Please update the Aspirin order to include the strength 81 mg. REPEATED RECOMMENDATION from 2/17/21. Review of the Medication Administration Record (MAR) for the months of February 2021 and March 2021 revealed documented orders for Aspirin Tablet Chewable-Give one tablet by mouth one time a day for CVA with a start date of 2/16/21. This medication was documented as administered daily from 2/16/21 through 3/31/21. Review of the MAR for April revealed documentation for Aspirin Tablet Chewable-Give 81 mg by mouth one time a day for CVA with a start date of 4/1/21. This medication was documented as administered from 4/1/21 through 5/20/21 (review date). The facility did not ensure the physician responded to the pharmacy recommendations in a timely manner as the order for the medication was not updated until 3/31/21. 2. Review of Resident #64's face sheet in the medical record revealed he/she was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Mood Disorder due to Known Physiological Condition, Anxiety Disorder, Restless and Agitation. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #64 had a BIMS score of 99, indicating severe cognitive impairment. Review of current Physician's Order for May 2021 revealed an order for Seroquel 25 mg via PEG (percutaneous endoscopic gastrostomy) tube one time a day for Mood Disorder related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION, UNSPECIFIED. This order was dated 2/8/21 with a start date of 2/9/21. Review of the Pharmacy Consultation Report dated 10/16/2020 noted a recommendation to update the medical record to include: 1. The specific diagnosis/indication requiring treatment that is based upon an assessment of the resident's condition and therapeutic goals; and 2. A list of the symptoms or target behaviors (example: hallucination, scratching) including their impact on the resident (example: increased distress, presents a danger to the resident or others, interferes with his/her ability to eat.) Pharmacy noted Resident #64, receives an antipsychotic. Quetiapine without an adequate indication for use. REPEATED RECOMMENDATION from 9/30/2020. The physician response stated Diagnosis in chart in PCC (Point Click Care) is R45.1. R45.1 is a diagnosis code for Restless and Agitation as noted on the diagnosis list for Resident #22. The physician did not provide the information requested by the Pharmacy Consultant. Review of the Pharmacy Consultation Report dated 11/17/2020 revealed the same recommendation as on the report dated 10/16/2020 and noted REPEAT RECOMMENDATION from 10/16/2020 and REPEATED RECOMMENDATION from 9/30/2020. The physician response was blank. Review of the Pharmacy Consultation Report dated 12/19/2020 revealed the same recommendation as on the report dated 10/16/2020 and noted REPEAT RECOMMEDATION from 11/17/2020, REPEAT RECOMMENDATION from 10/16/2020 and REPEATED RECOMMENDATION from 9/30/2020. The physician response was blank. Review of the Pharmacy Consultation Report dated 1/21/21 revealed the same recommendation as on the report dated 10/16/2020 and noted REPEAT RECOMMENDATION from 12/19/2020, REPEAT RECOMMEDATION from 11/17/2020, REPEAT RECOMMENDATION from 10/16/2020 and REPEATED RECOMMENDATION from 9/30/2020. The physician response noted: The requested documentation has been provided below, please update records accordingly. The Physician wrote: Mood Disorder and drew a line through it, Dementia (symbol for with) and drew a line through it and then wrote Dementia. Review of the Pharmacy Consultation Report dated 2/8/21 noted a recommendation to Please clarify the following items, communicating with the prescriber and pharmacy as appropriate: Psych consult from 1/20/21 shows ICD codes for dementia, mood disorder due to known physiological disorder and anxiety disorder. Please update facility records to list Seroquel for mood disorder due to know physiological disorder. This recommendation was completed 2/8/21 as noted on the current physician's orders. The facility did not ensure the physician responded in a timely manner to repeated pharmacy recommendations in September 2020, October 2020, November 2020, December 2020, and January 2021 as an appropriate diagnosis for Seroquel was not added until 2/8/21. Interview with the Director of Nursing (DON) at 3:45 p.m. on 5/20/21 revealed the DON and the Unit Managers (UM) receive the monthly pharmacy recommendations. He/she stated the facility's procedure was that the UM responsible for the unit where the resident resided was responsible to present the recommendation to the physician for his/her orders and follow up. The UM should enter the new order (if any) in the medical record and send the original recommendation sheet to medical records to scan to the electronic medical record. The DON was to follow up with the recommendations to ensure they have all been addressed in a timely manner. The DON confirmed this had not been completed as required per facility procedure for Resident #22 with the recommendation on 2/17/21 as the recommendation was not followed up on and completed until 3/31/21. The DON also confirmed the facility did not ensure Resident #64 had a proper indication for the use of Seroquel (an antipsychotic medication) as recommended on 9/30/2020, 10/16/2020, 11/17/2020, 12/19/2020, and 1/21/21 as the recommendation was not addressed until 2/8/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure each resident's medication profile was free from unnecessary psychotropic medications by failing to ensure an adequate indication for use of a psychotropic medication (Seroquel) for one (1) (Resident #64) of five (5) residents reviewed for unnecessary medications. Findings include: Review of facility policy titled Medication Regimen Review (MRR) with an effective date of 11/28/16 stated, 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. Review of Resident #64's face sheet in the medical record revealed he/she was admitted to the facility on [DATE]. Diagnoses included Dysphagia, Aphasia, Apraxia, Cerebral Infarction, Severe Protein Calorie Malnutrition, Mood Disorder due to Known Physiological Condition, Anxiety Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction, Seizures, Restless and Agitation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Review of current Physician's Order for May 2021 revealed an order for Seroquel 25 milligrams (mg) via PEG (percutaneous endoscopic gastrostomy) tube one (1) time a day for Mood Disorder related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION, UNSPECIFIED. The order was dated 2/8/21 with a start date of 2/9/21. Review of the Pharmacy Consultation Report dated 10/16/2020 noted a recommendation to update the medical record to include: 1. The specific diagnosis/indication requiring treatment that is based upon an assessment of the resident's condition and therapeutic goals; and 2. A list of the symptoms or target behaviors (example: hallucinations, scratching) including their impact on the resident (example: increases distress, presents a danger to the resident or others, interferes with his/her ability to eat.) Pharmacy noted Resident #64, receives an antipsychotic. Quetiapine without an adequate indication for use. REPEATED RECOMMENDATION from 9/30/2020. The physician response stated Diagnosis in chart in PCC (Point Click Care) is R45.1. R45.1 is a diagnosis code for Restless and Agitation as noted on the diagnosis list for Resident #22. The physician did not provide the information requested by the Pharmacy Consultant. Review of the Pharmacy Consultation Report dated 11/17/2020 revealed the same recommendation as on the report dated 10/16/2020 and noted REPEAT RECOMMENDATION from 10/16/2020 and REPEATED RECOMMENDATION from 9/30/2020. The physician response was blank. Review of the Pharmacy Consultation Report dated 12/19/2020 revealed the same recommendation as on the report dated 10/16/2020 and noted REPEAT RECOMMEDATION from 11/17/2020, REPEAT RECOMMENDATION from 10/16/2020 and REPEATED RECOMMENDATION from 9/30/2020. The physician response was blank. Review of the Pharmacy Consultation Report dated 1/21/21 revealed the same recommendation as on the report dated 10/16/2020 and noted REPEAT RECOMMENDATION from 12/19/2020, REPEAT RECOMMEDATION from 11/17/2020, REPEAT RECOMMENDATION from 10/16/2020 and REPEATED RECOMMENDATION from 9/30/2020. The physician response noted: The requested documentation has been provided below, please update records accordingly. The Physician wrote: Mood Disorder and drew a line through it, Dementia and (symbol for with) and drew a line through it and then wrote Dementia. Review of the Pharmacy Consultation Report dated 2/8/21 noted a recommendation to Please clarify the following items, communicating with the prescriber and pharmacy as appropriate: Psych consult from 1/20/21 shows ICD (Diagnoses) codes for dementia, mood disorder due to known physiological disorder and anxiety disorder. Please update facility records to list Seroquel for Mood disorder due to know physiological disorder. This recommendation to add an appropriate indication of use for Seroquel was completed 2/8/21 as noted on the current physician's orders. The facility did not ensure the physician responded in a timely to repeated pharmacy recommendations for an appropriate indication of use for Seroquel (an antipsychotic medication ) in September 2020, October 2020, November 2020, December 2020, and January 2021 as an appropriate diagnosis for Seroquel was not added until 2/8/21. Interview with the Director of Nursing (DON) at 3:45 p.m. on 5/20/21 revealed the DON and the Unit Managers (UM) receive the monthly pharmacy recommendations. He/she stated the facility procedure was that the UM responsible for the unit where the resident resided was responsible to present the recommendation to the physician for his orders and follow up. The UM should enter the new order (if any) in the medical record and send the original recommendation sheet to medical records to scan to the electronic medical record. The DON is to follow up with the recommendations to ensure they have all been addressed in a timely manner. The DON confirmed the facility did not ensure Resident #64 had a proper indication for use of Seroquel (an antipsychotic medication) as recommended by pharmacy on 9/30/2020, 10/16/2020, 11/17/2020, 12/19/2020, and 1/21/21 as the recommendation was not addressed until 2/8/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policy, the facility failed to ensure the residents did not receive expired medications on two (2) of three (3) medication carts observed including medications for three (3) residents (Resident #106, #220, and #94). Findings include: Review of the policy titled, Insulin Storage Recommendations dated 3/2020 revealed Basaglar Insulin pen, Novolog flexpen, and Lispro pen should be used within 28 days after opening when stored at room temperature. Humulin N pen should be used within 14 days after opening when stored at room temperature. Observation of the medication cart on the [NAME] Unit on 5/19/21 at 9:40 a.m. revealed a bottle of Milk of Magnesium (MOM) with the expiration date of 4/2021. Observation of the medication cart on the [NAME] Unit on 5/20/21 at 9:10 a.m. revealed a bottle of MOM with the expiration date of 4/2021. Further observation of that cart revealed Resident #106's Basaglar Insulin pen with the opened date of 3/7/21, Humulin N pen with the opened date of 3/27/21 and Novolog Flexpen with the opened date 3/29/21 for Resident #220 and Lispro Insulin pen for Resident #94 opened on 4/8/21. Interview with Registered Nurse (RN) #1 on 5/20/21 at 9:10 a.m. stated the insulin pens were good for 28 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and facility policy, the facility failed to develop a comprehensive care plan and/or implement the care plan for five (5) of 25 residents reviewed (Resident #105, #31, #15, #81, and #41). Findings include: Review of the policy titled Care Plans, Comprehensive Person-Centered dated 12/2016 revealed the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. When possible, interventions address the underlying source(s) of the problem area (s), not just addressing only symptoms or triggers. Interview with the Director of Nursing (DON) on 5/21/21 at 9:18 a.m. revealed the Minimum Data Set (MDS) Manager should be auditing care plans weekly to be sure they were correct for the resident. Interview with the MDS Manager on 5/21/21 at 11:04 a.m. revealed the care plans were completed by the Social Worker, Activity staff, MDS staff, Nursing and Registered Dietician (RD). He/she further agreed the care plans were not individualized for the residents. Review of Resident #105's clinical record revealed an admission date of 8/17/2020 and the diagnoses included Encephalopathy, Parkinson's Disease and Dementia. Review of Resident #105's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 with a score of eight (8) to 12 indicating modified cognition. The resident displayed verbal behaviors one (1) to three (3) days during the seven (7) day observation period. The resident required extensive assistance of one (1) staff with bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing. The resident was not steady and only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around and facing the opposite direction, and moving on and off the toilet. The resident was frequently incontinent of bowel and bladder and utilized a walker and wheelchair. The MDS revealed the resident received Occupational Therapy (OT) and Physical Therapy (PT) four (4) days during the observation period. 1. Review of the Fall Investigations, Nurses' Notes and Care Plan revealed: 9/28/2020 at 3:35 p.m. - the resident was yelling, and staff found the resident leaning on the side of bed with legs partially off the bed. Staff assisted the resident to the floor. Staff brought the resident to the Day Room for closer observations and initiated floor mats. 1/23/21 at 11:07 a.m. - staff found the resident on the floor by his/her bed. Staff initiated increase rounding but did not specify the frequency. 4/10/21 at 7:44 a.m. - staff found the resident on floor next to his/her bed. The resident complained the his/her left hip hurt. The facility sent the resident to the hospital where he was diagnosed with a left hip fracture. The resident returned to the facility on 4/19/21. Staff added a scoop mattress and on 4/12/12 and for the bed to be in the lowest position. 4/24/21 at 11:33 a.m. - staff found the resident on the floor with a skin tear to his/her left hand and right lateral knee. The staff placed nonskid socks, floor mats, again, and placed the bed in a low position again. 5/19/21 at 11:53 p.m. - staff found the resident laying on his/her stomach on the floor. The resident had blood to the middle and ring finger and complained of hip pain. The facility sent the resident to hospital and returned with no new injuries identified. Staff added the intervention to keep the wheelchair at the side of the bed and the wheels locked. Observation on 5/18/21 at 1:21 p.m. revealed the resident lying in a low bed a fall mat next to the bed on the right side and fall mat on the left side 18 inches away from the bed. Observation on 5/19/21 at 9:03 a.m. revealed the resident lying in a low bed, a fall mat on the right side next to the bed and the fall mat on the left side 18 inches away from the bed. Observation on 5/19/21 at 12:04 p.m., 12:36 p.m. and 12:51 p.m. revealed the resident in bed, with the right fall mat next to the bed and the left fall mat 18 inches from the bed. Further observation revealed the height of the bed at the regular height and not in a low position. Observation on 5/20/21 at 8:37 a.m., 8:49 a.m. and 10:32 a.m. revealed the resident lying in bed. The bed was 22 inches off the floor and the call light was on the floor. The right floor mat was 12 inches away from the bed and the left floor mat was next to the bed. Interview with Certified Nurse Assistant (CNA) #7 on 5/20/21 at 10:54 a.m. revealed Resident #105's fall prevention interventions included we keep him/her occupied outside his/her room with activities, out of his/her room for meals, if he/she got agitated they knew he/she wanted to go to bed so they distracted him/her, and he/she liked milk and cookies. CNA #7 stated he had a low bed and a fall mat. 2. Review of Resident #31's clinical record revealed an admission date of 2/5/21 and the diagnoses included: Hemiplegia; Dysphagia; Mood Disorder; Anxiety Disorder; Anorexia; and Developmental Disorder of Scholastic Skills. Review of Resident #31's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of five (5) with a score of zero (0) to eight (8) indicated severe cognitive impairment. The MDS revealed the resident required extensive assistance of two (2) staff with bed mobility, locomotion, dressing, eating, and personal hygiene. The resident weighed 122 pounds and had the presence of weight loss and was not on a physician prescribed weight loss program. The MDS revealed the resident did not have dental issues and held food in his/her mouth. Review of the Dietary Interview/Pre-Screen assessment dated [DATE] revealed Resident #31 wanted coffee at breakfast and lemonade at lunch and dinner. The resident liked snacks and yogurt and disliked fried, scrambled, and poached eggs and did not like fish or grits. Review of the Weight List revealed Resident #31 lost 51.8 pounds or 34.77 percent from 2/5/21 to 5/19/21. Review of Resident #31's Care Plan dated 3/14/21 listed the interventions: 2/24/21: Resident needed assistance of one (1) staff to eat and drink. 2/25/21: Diet and liquids per physician order, regular diet and texture, thin liquid consistency and finger foods, Dietician to review as indicated for dietary recommendations, exclude food intolerance and allergies from meals, honor religious food preferences, snack at bedtime related to Diabetes, labs per order and notify physician of results, refer to speech therapy as indicated for difficulty with eating, snacks per preference/request, supplements per order and offer decreased calories in meals (for a resident losing weight). 3/11/21 - Occupational and Speech Therapy to evaluate and treat as ordered. Review of Resident #31's Physician's Orders included: 2/25/21 - regular diet of regular texture and thin liquids. 3/19/21 - Ensure Plus, one (1) can, three (3) times a day. 4/15/21 - Prostat 30 cubic centimeters (cc) three times a day for wound healing. 4/16/21 - Mighty Shake with meals. 5/7/21 - Magic Cup, one (1) time a day with lunch. 5/12/21 - Weigh every Wednesday. Observation on 5/18/21 at 1:42 p.m. revealed Resident #31 sat in a high back wheelchair in his/her room with a Mighty Shake and frozen supplement on the overbed table in front of him/her. No staff were present in the room to assist the resident. Observation on 5/19/21 at 11:58 a.m. revealed Resident #31 sat in a wheelchair in his/her room and Certified Nursing Assistant (CNA) present in the room. The meal consisted of egg salad sandwich, pasta salad, lettuce salad, cookie, Magic Cup, health shake and tea. The staff did not provide him/her lemonade as per his/her choice. Further observation revealed the CNA's cell phone went off and then the CNA was noted to be texting on the cell phone while sitting in the resident's room and not assisting the resident with his/her lunch meal. Observation on 5/19/21 at 12:08 p.m. revealed staff removed the lunch tray from the room and the resident ate one (1) bite of the egg salad sandwich, 75 percent (%) of the pasta salad, four (4) ounces (oz) of Mighty Shake, one (1) bite of Magic Cup, and 25% of lettuce salad. Review of the Meal Intake in the CNA's computer documentation, revealed staff documented the resident ate 76 to 100 percent of the noon meal that day. Observation on 5/20/21 at 8:39 a.m. revealed the resident laid in bed with the breakfast tray in front of him or her, not eating and no staff were present. The breakfast meal consisted of Health Shake, hot cereal, toast, orange juice, and scrambled egg casserole. The staff did not provide coffee as per the resident's choice but provided scrambled egg casserole against the resident's choice. Observation on 5/20/21 at 8:42 p.m. revealed staff removed the tray from the room and the resident had only consumed the orange juice and the Health Shake. Review of the Diet Slip at that time revealed the resident received a regular diet, finger foods, Magic cup with lunch, eight (8) ounces of coffee or tea. Review of the Meal Intake in the CNA's computer documentation revealed staff documented the resident ate zero (0) to 25 percent of the breakfast meal that day. Observation on 5/20/21 at 12:04 p.m. revealed the uncovered lunch tray on the overbed table, the resident was not eating, and no staff were present in the room. Observation on 5/20/21 at 12:21 p.m. (17 minutes after meal was observed uncovered) revealed CNA #7 entered the room and stood by the resident's bed without providing assistance with eating per the care plan. Observation on 5/20/21 at 12:26 p.m. revealed staff removed the lunch tray from the room. Further observation at that time revealed the resident drank two (2) ounces of the Mighty Shake, glass of ice tea, 50% of the piece of cake, but did not eat any of the country fried steak with cream gravy, mashed potatoes, peas, dinner roll, or the frozen nutritional treat. Staff did not provide the resident's choice for lemonade. Review of the Meal Intake in the CNA's computer documentation revealed staff documented the resident ate 26 to 50 percent of the noon meal that day. Interview with Licensed Practical Nurse (LPN) #5 on 5/20/21 at 10:46 a.m. revealed Resident #31 required total assistance with eating. The resident also received a Magic cup which the nurses would document the percentage eaten. The resident also received Ensure and Mighty Shakes which the nurses did not document the amount consumed, but only placed a check mark indicating the nurses gave the supplement but not how much was consumed. Interview with CNA #7 on 5/20/21 at 10:58 a.m. revealed Resident #31 required total assistance with meals. Interview with the Dietary Manager on 5/20/21 at 12:34 p.m. confirmed the resident's Dietary Slip did not include the lemonade the resident requested at lunch and dinner. He/she further stated the staff on the unit were responsible for providing the coffee to the resident. 3. Review of Resident #15's clinical record revealed an admission date of 7/16/19 and a readmission date of 6/24/2020 and the diagnoses included: Dementia with Behavioral Disturbance; Epilepsy; Anxiety Disorder; Diabetes; and Abnormal Posture. Review of Resident #15's Quarterly MDS assessment dated [DATE] revealed a BIMS score of four (4) with a score of zero (0) to eight (8) indicating severe cognition impairment. The MDS revealed the resident required extensive assistance of one (1) staff for bed mobility, dressing, eating, toilet use and personal hygiene. The MDS revealed the resident required total assistance of two (2) staff with transfers and bathing and required total staff assistance of one (1) staff with locomotion and did not ambulate. The resident was frequently incontinent of bowel and bladder and had one (1) Stage two (II) pressure ulcer and had a pressure relieving device in the chair and pressure relieving mattress on the bed. Resident #15's MDS revealed the resident had a significant weight gain. Review of Resident #15's Care Plan dated 3/3/21 listed the interventions for Sacral Pressure Ulcers to include: supplements as ordered for wound healing and Wound Nurse to follow as indicated. Review of the Care Plan for Resident #15 revealed Resident at Risk for Skin Breakdown, resident has discoloration to feet with the initiated date of 7/17/19 listed the interventions: 7/17/19 - if an ulcer developed notify the wound nurse, family and physician, observe skin through daily care provisions, pressure reduction wheelchair cushion per order, provide daily preventative skin care, provide incontinent care as indicated, Registered Dietician (RD) to review and make nutritional recommendations as indicated, refer to podiatrist as needed for preventative foot care, turn and re-position as indicated, weekly nursing assessment to observe for skin breakdown, and use pillow to offload pressure from heels as indicated. 11/23/2020 - apply treatment to bilateral feet as ordered, supplements as ordered for wound healing and treatment per order and Wound Nurse to follow as indicated. Review of Resident #15's Physician's Orders revealed an order to elevate bilateral extremities while in bed and chair every shift for edema with the ordered date on 1/28/2020. Review of the orders revealed an order for Prostat Sugar Free 30 cubic centimeters (cc) two times a day as a dietary supplement for wound care ordered on 9/4/2020. Apply skin prep to all discoloration on bilateral feet every shift with the start date of 11/21/2020 and treatment to pressure ulcer on the coccyx revised on 5/3/21. Review of the Nurse's Note dated 5/10/21 at 3:34 p.m. revealed the resident required total care with activities of daily living (ADLs), was out of bed to the geriatric chair (g-chair) (chair that reclined and legs/feet could be elevated). Observation of Resident #15 on 5/19/21 at 12:06 p.m., 12:39 p.m. and 12:52 p.m., revealed the resident sat in a g-chair with feet hanging down unsupported and no pressure relieving device was in the chair. Observation on 5/20/21 at 10:44 a.m. revealed the resident laid in bed on his/her left side and the feet not elevated off the bed. Observation on 5/20/21 beginning at 11:13 a.m. with the Wound Care Nurse and the Nurse Staffing Coordinator revealed they provided wound care to the pressure ulcer on the coccyx. At the end of the treatment, the surveyor asked to do a skin check of the feet. Observation at that time revealed the feet lying directly on top of each other and not elevated off the bed. Further observation when staff removed the top foot off the bottom foot revealed an open area to the top/side of the right foot. The Wound Care Nurse stated the area was new and he/she would talk with the provider for a treatment order since it was an open area. Staff did not place a protective dressing and did not provide pressure relief to the feet prior to covering the resident up with blankets. Review of the Skin and Wound Evaluation dated 5/21/21 revealed the Wound Care Nurse measured the Stage II pressure ulcer as 1.7 centimeters (cm) by 1.5 cm. on the upper side of the right foot. 4. Review of Resident #81's clinical record revealed an admission dated of 8/19/2020 and the diagnoses included: Aphasia following Cerebral Infarction; Dementia with Behavioral Disturbance; Hereditary Motor and sensory Neuropathy; Adjustment Insomnia; Anxiety Disorder; Muscle Weakness; and Major Depressive Disorder Severe, with Psychotic Symptoms. Review of Resident #81's admission MDS assessment dated [DATE] revealed the resident had a BIMS score of nine (9) with a score of eight (8) to 12 indicating moderately impaired cognition. The resident displayed inattention and disorganized thinking continuously that did not fluctuate and verbal behaviors one (1) to three (3) days of the seven (7) day observation period. The MDS also revealed the resident required extensive assistance of one (1) staff with bed mobility, dressing, toilet use, personal hygiene and bathing. The resident required extensive assistance of two (2) staff with bed mobility and required limited assistance of one (1) staff with walking, locomotion and eating. The resident had impairment on both sides of the lower extremities and was not steady but able to stabilize without staff assistance with moving from a seated to standing position, and not steady and only able to stabilize with staff assistance with walking, turning around and facing the opposite direction, moving on and off the toilet and surface to surface transfers. The MDS revealed the resident used a walker and wheelchair, was frequently incontinent of bowel and bladder and the staff were unable to determine the resident's history of falls prior to admission. The resident had no falls since admission and did not receive therapy services. Review of the Care Plan listed the interventions dated 8/31/2020: Bed in lowest position. Fall Risk Assessment per policy to evaluate risk for falls. Non-skid socks or footwear. Notify physician and power of attorney of all falls. Observe for side effects from medications and if adverse effect that could increase risk for falls. occurs, notify the physician. PT/OT to evaluate and treat as indicated. Re-orient as needed. Review of the Fall Investigations, Nurses' Notes and Care Plan revealed: 9/20/2020 at 6:14 p.m. - staff found the resident on the floor in the locked employee bathroom with the intervention for staff to stay with the resident in the bathroom due to unsteadiness and dementia. 10/24/2020 at 4:35 p.m. - staff heard the resident yelling and found him/her on the floor in his/her room. Staff added the intervention to remove the resident from his/her room after dressing. 11/20/2020 at 7:10 p.m. - staff found the resident on the floor by his/her wheelchair. Staff added the intervention to offer to toilet and offer to put the resident to bed after supper. 1/15/21 at 8:08 a.m. - the resident attempted to get out of bed unassisted, into wheelchair. The resident slid off low bed onto the floor. The intervention included for staff to offer the resident to get out of bed into a wheelchair if he/she woke up early. 2/2/21 at 5:31 a.m. - staff found the resident at the foot of the low bed and sustained a head laceration but did not receive sutures. Staff did not provide an investigation of this fall upon asking. 3/18/21 at 10:42 a.m. - staff found the resident on the floor by the bed. Staff added the intervention for floor mats and to confirm the mats were in place every shift. The resident sustained a hematoma to the left eye and forehead. 5/7/21 at 12:38 a.m. - staff found the resident on the floor mat by the bed. Staff added the intervention for frequent checks and scoop mattress. Observation on 5/19/21 at 9:01 a.m. revealed the resident sat in a wheelchair in his/her room with the door to the room closed. Observation on 5/19/21 at 11:56 a.m. and 12:52 a.m., revealed the resident sat in a wheelchair in his/her room with his/her back to the door. Observation on 5/20/21 at 8:41 a.m. revealed the resident lying in bed with a wing mattress present. The privacy curtain was pulled between her bed and door, and the staff could not see the resident from the door/hallway. Further observation revealed no fall mats were present. Observation on 5/20/21 at 10:30 a.m. revealed the resident laying in a low bed and no fall mats were present. Observation on 5/20/21 at 12:06 p.m. revealed the resident lying in bed positioned at regular height and no staff were present. 5. Review of Resident #41's clinical record revealed an admission date of 4/19/17 and the diagnoses included: Anoxic Brain Damage; Tracheostomy Status; Gastrostomy (g-tube) Status; Aphasia; and Cerebral Infarction. Review of Resident #41's Care Plan dated 3/25/21 for the presence of a Tracheostomy with the initiation date of 4/19/17 included the interventions: ensure trach ties were secure at all times; oxygen saturations per physician's orders, observe respiratory rate, depth and quality every shift/as ordered; standard precautions as appropriate; suction trach every shift and as necessary; Trach number four (4) reusable; trach care every shift; tube out procedures - keep extra trach tube and obturator at bedside. If the tube is coughed out, spread stoma with fingertips and gently reinsert new trach. Do not force. If unable to reinsert, try next smaller size. If unable to reinsert call 911 and remain with the resident. Review of the oxygen saturation record from 5/1/2020 to 5/20/21 revealed staff documented the oxygen saturation as on room air or on trach. Observation and interview with Licensed Practical Nurse (LPN) #4 on 5/18/19 at 2:15 p.m. revealed the staff had an ambu bag at the bedside, a trach cleaning kit and several size 4 cannulas. Further observation and interview revealed a suction machine at the bedside but no unused suctioning tubing at the bedside; LPN #4 stated he/she gave the extra one to another nurse that needed it. LPN #4 also stated the facility did not keep a smaller size than a four for Resident #41. LPN # 4 did not find an obturator in the room. Observation revealed the compressor, set at 240, on a dresser in the room but the compressor hose was stretched tight to the resident and the mask was pulled to the side of the resident's trach, not providing oxygen to the resident. Interview with Director of Nursing on 5/21/21 at 9:18 a.m. revealed each resident with a trach should have a suction kit, ambu bag, extra trach, smaller size trach, obturator and suction machine at the bedside. Staff should document the oxygen saturation of residents with trachs as checked under trach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure that tracheostomy supplies were kept at the bedside and that residents were provided care consistent with professional standards of practice for three (3) of three (3) residents reviewed for tracheostomy care (Resident #6, #41 and #324). Observation of Resident #6's tracheostomy care revealed that care was not performed in accordance with professional standards of practice. Observation of Resident #6's room revealed the resident's current size or a size down inner cannula and a suction kit was not at the bedside. Observation of Resident #41's tracheostomy care revealed that care was not performed in accordance with professional standards of practice. Observation of Resident #41's room revealed a size down inner canula and suction kit was not at the bedside. Observation of Resident #324's tracheostomy care revealed that care was not performed in accordance with professional standards of practice. Observation of Resident #324's room revealed a suction kit was not at bedside. Findings include: Review of the facility policy titled Tracheostomy care with a revised date of August 2013 revealed General Guidelines 1. Aseptic technique must be used; a. During cleaning and sterilization of reusable tracheostomy tubes; b. During all dressing changes until the tracheostomy wound has granulated (healed); and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. 3. A mask and eyewear must be worn if splashes, splattering, or spraying of blood or bodily fluids is likely to occur when performing this procedure. 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly.) 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 6. A replacement tracheostomy tube must be available at the bedside at all times. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. 1. Resident #6 was admitted on [DATE] with diagnoses including but not limited to, Chronic Respiratory Failure with Hypoxia, Dysphagia, Pharyngeal, Dysphagia, Oropharyngeal Phase, Tracheostomy Status, and Functional Quadriplegia, Quadriplegia, Unspecified. Review of Resident #6's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 meaning the resident had severe cognitive impairment. Review of Resident #6's Quarterly MDS assessment review dated 2/16/21 revealed under special treatments and programs that while a resident oxygen therapy, suctioning, and tracheostomy care were checked. Review of Resident #6's Physician's Orders dated 5/18/21 revealed Tracheostomy care every shift and prn [as needed] using aseptic technique every shift. Review of Resident #6 Respiratory Note dated 7/6/2020 revealed .Emergency setup is not in the room, just the ambu bag is present. Central supply and Nurse was made aware of it Review of Resident #6 Respiratory Note dated 1/4/21 revealed .There was not an emergency package setup in the room of the size below to put in case the airway size decreased during changeout . During an observation of tracheotomy care on 5/18/21 at 1:40 p.m. Licensed Practical Nurse (LPN) #3 entered Resident #6's room. LPN #3 looked in the room for tracheostomy supplies, however, supplies were not available, and the LPN exited the room. LPN #3 returned and stated that s/he could not find a suction kit, s/he stated you want me to do it with no suction or go and find a suction kit and the surveyor stated that s/he was only there to observe and could not provide direction to the LPN. The LPN then left the room again. LPN #3 returned with a suction kit. LPN #3 had the following supplies: Sterile gloves, mask, tracheotomy care kit, sterile water, and suction catheter kit. LPN #3 performed tracheostomy care following the Tracheostomy Care procedure steps except s/he failed to check the physician's order and did not introduce her/himself and explain the procedure to the resident that s/he was going to perform. LPN #3 did not measure Resident #6's oxygen saturation with a pulse oximeter to check for respiratory distress. LPN #3 failed to use hydrogen peroxide and failed to set up a sterile field. LPN #3 failed to maintain aseptic technique by putting her gloved hands in the trash can and continued with care without changing the gloves. She also touched the outside of the sterile glove while putting them on. LPN #3 failed to ensure that there was an emergency tracheostomy set up at the resident's bedside. During an observation of tracheotomy care on 5/20/21 at 1:17 p.m. LPN #3 verified Resident #6's orders and introduced her/himself to Resident #6 and explained the procedure s/he was going to perform. LPN #3 failed to assess Resident #6 for respiratory distress prior to tracheostomy care. LPN #3 failed to use hydrogen peroxide and failed to maintain aseptic technique. Observation of Resident #6's room revealed that there was no size down inner canula available at bed side. Additionally, LPN #3 failed to ensure that there was an emergency tracheostomy set up at the resident's bedside. 2. Resident #324 was admitted to the facility on [DATE] with diagnoses including but not limited to, Malignant Neoplasm of larynx, Unspecified and Encounter for Attention to tracheostomy. Review of Resident #324's admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident had intact cognition. Further review revealed under special treatments and programs that while a resident, oxygen therapy, suctioning, and tracheostomy care were checked. Review of Resident #324's Physician's Order dated 5/12/21 revealed Tracheostomy care every shift and prn [as needed] every shift for trach. Review of Resident #324's Respiratory Note dated 5/4/21 revealed RT [respiratory therapy] assess patient. Air compressor was missing the adapter for the water bottle. RT supplied that for the compressor . During an observation on 5/21/21 at 11:56 a.m. Registered Nurse (RN) #2 performed tracheostomy care for Resident #324. RN #2 failed to check the physician's order and failed to assess Resident #324 for respiratory distress. RN #2 failed to use hydrogen peroxide and failed to clean the stoma and replace gauze around the insertion site. RN #3 failed to maintain aseptic technique. RN #2 failed to ensure that there was an emergency tracheostomy set up at the resident's bedside. During a phone interview on 5/21/21 at 2:34 p.m. with Respiratory Therapist (RT) #1, s/he stated that s/he visited the facility 2-3 times a month. Resident #6 was a resident that s/he visited. RT #1 stated that it was the responsibility of the facility to have all supplies needed for tracheotomy care. RT #1 stated that s/he has held training at the facility, s/he could not provide dates but stated that when s/he held training it was a 3-hour training. S/he would bring training manikins and would go over all the steps from start to finish for tracheostomy care. S/he stated that a skills check was completed at the end. RT #1 stated that very little staff at this facility would attend the training and when they did, they did not stay for the whole training. RT #1 stated that staff would say I know how to do this and I do not need training. During an interview on 5/21/21 at 3:10 p.m. with the Administrator, s/he stated that nursing staff went through orientation and skill checks when hired. The nursing staff would shadow other nurses on the floor and additional training would be given depending on where the nurse would be assigned. The Administrator stated that s/he started his/her position in August of 2020. When s/he came into the position s/he assumed processes where in place, when things came to light s/he made staffing changes, the DON was removed, and the Administrator hired extra staff. The Administrator stated that it would take some time to sort out new processes. During an interview on 5/21/21 at 3:18 p.m. with the Director of Staff Development and Infection Control. S/he stated that newly hired nurses did not have orientation training on tracheostomy care. S/he stated that s/he started tracheostomy care training last week. The Director of Staff Development and Infection Control stated that LPN #3 had not had training on tracheostomy care and had not had the skills check completed. The Director of Staff Development and Infection Control stated that RN #2 did not have tracheostomy care training during orientation and received the training last week with skills check. Review of RN #2's tracheostomy training and skills check revealed it was dated 5/21/21 as completed. During an interview on 5/21/21 at 9:18 a.m. with the Director of Nursing (DON). S/he stated that s/he expected staff to follow the facility policy on tracheostomy care and guidelines for aseptic technique. 3. Review of Resident #41's clinical record revealed an admission date of 4/19/17 and the diagnoses included: Anoxic Brain Damage; Tracheostomy Status; Gastrostomy (g-tube) Status; Aphasia; and Cerebral Infarction. Review of Resident #41's Physician's Orders for May 2021 revealed: Trach care every shift with number (#) four (4) Disposable Trach, suction trach every shift and as needed every shift, oxygen (O2) via trach at four (4) liters per minute (LPM), and oxygen saturations every shift. Review of Resident #41's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the staff did not assess for Resident #41's trach, use of oxygen and suctioning. Review of Resident #41's Care Plan dated 3/25/21 revealed the presence of a Tracheostomy with the initiation date of 4/19/17 included the interventions: ensure trach ties were secure at all times; oxygen saturations per physician's orders, observe respiratory rate, depth and quality every shift/as ordered; standard precautions as appropriate; suction trach every shift and as necessary; Trach number four (4) reusable; trach care every shift; tube out procedures - keep extra trach tube and obturator at bedside. If the tube is coughed out, spread stoma with fingertips and gently reinsert new trach. Do not force. If unable to reinsert, try next smaller size. If unable to reinsert call 911 and remain with the resident. Review of Resident #41's Nursing Progress Note dated 8/5/2020 revealed respiratory here to change out the trach tube but not able to due to central supply did not have the right size here. The breath sounds were coarse. Respiratory would come back when the right size of trach is available. Review of Resident #41's Nursing Progress Note dated 8/24/2020 revealed respiratory was here to change out the trach. Further review of the Progress Notes and the Nurses' Notes revealed the staff found the trach out on 8/28/2020, 9/21/2020, 11/15/2020, 11/29/2020, 12/7/2020, 12/23/2020, 2/16/21, and 2/29/21 and the staff transferred Resident #41 to the hospital each time to have the trach replaced after staff could not insert a new trach. Review of the oxygen saturation record from 5/1/2020 to 5/20/21 revealed staff documented the oxygen saturation as on room air or on trach. Observation on 5/18/21 at 11:45 a.m. revealed the resident lying in bed on his/her back with a trach present and the oxygen mask over the trach. The oxygen was at four (4) LPM. Observation and interview with Licensed Practical Nurse (LPN) #4 on 5/18/21 at 2:15 p.m. revealed the staff had an ambu bag at the bedside, a trach cleaning kit and several size 4 cannulas. Further observation and interview revealed a suction machine at the bedside but no unused suctioning tubing at the bedside; LPN #4 stated he/she gave the extra one to another nurse that needed it. LPN #4 also stated the facility did not keep a smaller size than a four for Resident #41. LPN # 4 did not find an obturator in the room. Observation revealed the compressor, set at 240, on a dresser in the room but the compressor hose was stretched tight to the resident and the mask was pulled to the side of the resident's trach, not providing oxygen to the resident. Observation on 5/20/21 at 11:30 a.m. revealed LPN #4 provided trach care while wearing a mask but not a face shield. Observation revealed LPN #4 removed the old trach dressing without gloves on, washed her hands, opened the trach kit, removed the barrier and package of gloves and placed the supplies on the overbed table. The nurse then turned over the trach container to remove the additional items out of the kit. The nurse then donned gloves, removed the inner cannula and placed it in the peroxide. LPN #4 then used the brush to clean the white plastic trach holder and q tips to clean under the holder. The nurse tried to clean the cannula by swishing it back and forth in the peroxide, then into the sterile water, then back into the peroxide and then tapping it on the end of the cannula multiple times, and then repeated this process multiple times trying to get the yellow mucus out of the cannula. The nurse then went and opened the cabinet looking for another trach kit. She was unable to find one and then went back to attempting to clean the cannula with the same gloved hands. The nurse rolled up a four by four gauze and attempted to insert it into the cannula without success. LPN #4 then stated he/she needed to get another trach kit and replaced the cannula back into the opening without changing his/her gloves. LPN #4 left the room without putting the oxygen mask over the trach opening. LPN #4 then came back to the room, did not wash his/her hands, and opened the trach kit, removed the barrier and the gloves and then turned over the trach kit emptying the additional supplies out of the kit. The nurse then donned gloves, cleansed the inner cannula, and reinserted it in the trach. The nurse did not assess the resident's respiratory status, prior, during or after trach care was completed. Review of the Skills Competency Evaluation for LPN #4 for Tracheostomy Care revealed the facility provided the Competency Evaluation dated 5/21/21, after the above observation. Interview with the Director of Nursing (DON) on 5/21/21 at 9:18 a.m. revealed each resident with a trach should have a suction kit, ambu bag, extra trach, smaller size trach, obturator and suction machine at the bedside. Staff should document the oxygen saturation of residents with trachs as checked under trach. The staff should go to the drop-down box and pick trach or else it documented the oxygen saturation was done as room air. The surveyor inquired as to why Resident #41's trach came out multiple times and the DON stated he/she would investigate it. Interview with the DON on 5/21/21 at 4:55 p.m. revealed he/she did not have any information as to why Resident #41's trach came out on multiple occasions.

Based on observation, record review, interviews and review of facility policy, the facility failed to ensure the medication error rate was less than five (5) percent. Observation of medication administration on 5/19/21 and 5/20/21, revealed 28 medication opportunities were observed with 5 errors, resulting in a medication error rate of 17.85 percent. The facility failed to provide medications as ordered and/or in the technique required for two (2) of four (4) residents observed (Resident #42 and Resident #279). Findings include: Review of the policy titled, Administering Medications dated 4/2019 revealed, medications were administered in accordance with prescriber orders, including any required time frame. The individual administering the medication, checks the label three (3) times to verify the right resident, right dosage, right time, and right method of administration before giving the medication. Observation of medication administration on 5/19/21 at 9:44 a.m. revealed Licensed Practical Nurse (LPN) #4 provided Resident #42 his/her medications. The medications included Vitamin B12 (supplement), 500 micrograms (mcg). LPN #4 gave the resident two (2) whole tablets and four (4) one half tablets, consisting of 2000 mcg mixed with the other medications. LPN #4 did not tell the resident to place them under his tongue. Further observation revealed LPN #4 administered two (2) sprays of Flonase 120 into each nostril without instructing the resident to blow his nose first or hold the opposite nostril closed while administering the sprays. Review of Resident #42's Physician Orders revealed the order for: Vitamin B12, 2500 mcg sublingually every day, with the ordered date of 12/15/21 Flonase 120 metered inhaler, two (2) sprays into each nostril every day with the ordered date of 3/23/2020. According to www.flonase.com instruction for use included to have the resident blow their nose first and then close the opposite nostril when administering the nasal spray. Artificial Tears, one (1) drop in both eyes two (2) times a day scheduled for 9:00 a.m. and 6:00 p.m. with the ordered date of 1/22/21. Observation revealed LPN #4 did not administer the Artificial Tears. Observation on 5/20/21 at 8:59 a.m. revealed Registered Nurse (RN) #1 administered medications to Resident #279. Further observation revealed the resident received Magnesium (supplement) 250 milligrams (mg). Review of Resident #279's Physician Orders revealed: Magnesium 800 mg every day, scheduled for 9:00 a.m. Folic Acid one (1) mg every day scheduled for 9:00 a.m. Observation revealed RN #1 did not administer the Folic Acid. Interview with RN #1 on 5/21/21 at 12:31 p.m. revealed he/she did not realize he/she gave the wrong dose of the magnesium and stated the staff should administer medications as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure that staff demonstrated proper aseptic technique during tracheostomy care for three (3) of three (3) residents reviewed (Resident #6, #41 and #324). Additionally, staff failed to implement appropriate processes to avoid contamination of ice for residents drinking water on two (2) of six (6) halls. Aseptic technique was not maintained during tracheostomy care for Resident #6, Resident #324 and Resident #41. Five (5) observations were made of staff placing the ice scoop in the ice chest for storage after refilling residents' cups. Ice scoop handles were observed touching the ice within the ice chest. Findings include: Review of the facility policy titled Infection Control with a revised date of October 2018 revealed under Policy statement this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. Under policy interpretation and implementation This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. Review of the facility policy titled Tracheostomy Care with a revised date of August 2013 revealed General Guidelines 1. Aseptic technique must be used; a. During cleaning and sterilization of reusable tracheostomy tubes; b. During all dressing changes until the tracheostomy wound has granulated (healed); and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. 3. A mask and eyewear must be worn if splashes, splattering, or spraying of blood or bodily fluids is likely to occur when performing this procedure Aseptic technique must be used during all dressing changes or cleaning of re-suable tracheostomy tubes. Gloves must be used on both hands during any or all manipulation of the tracheostomy. A mask and eyewear must be worn if splashes, spattering, or spraying of blood or body fluids was likely to occur when performing this procedure. Review of the Facility policy titled Ice Machines and Ice Storage Chests with a revised date of January 2012 revealed Ice-making machines, ice storage chests/containers, and ice can all become contaminated by: a. Unsanitary manipulation by employees, residents, and visitors; . To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: .e. Keep the ice scoop/bin in a covered container when not in use. (Note: If the ice scoop is maintained on a chain, be sure the chain is short enough to ensure the scoop does not touch the floor.); . 1. During an observation of tracheotomy care for Resident #6 on 5/18/21 at 1:40 p.m. Licensed Practical Nurse (LPN) #3 failed to maintain aseptic technique. LPN #3 was observed three (3) times during care pushing down on trash in the trash can with his/her right gloved hand. LPN #3 did not remove the gloves after and continued with tracheostomy care. LPN #3 was observed touching surfaces near the resident's bed with gloved hands. LPN #3 did not remove the gloves after and continued with tracheostomy care. Moreover, LPN #3 failed to set up a sterile field for tracheostomy care. During an observation of tracheotomy care for Resident #6 on 5/20/21 at 1:17 a.m. LPN #3 failed to maintain aseptic technique. LPN #3 was observed touching surfaces near the resident's bed with gloved hands. LPN #3 did not remove gloves after and continued with tracheostomy care. 2. During an observation of tracheotomy care for Resident #324 on 5/21/21 at 11:56 a.m. Registered Nurse (RN) #2 failed to maintain aseptic technique. RN #2 was observed touching surfaces near the resident's bed with gloved hands. RN #2 did not remove the gloves after and continued with tracheostomy care. RN #2 was observed placing soiled gloves on the resident's bed not in the trash can. During an interview on 5/21/21 at 3:18 p.m. with the Director of Staff Development and Infection Control. S/he stated that newly hired nurses did not have orientation training on tracheostomy care. S/he stated that s/he started tracheostomy care training this week. The Director of Staff Development and Infection Control stated that LPN #3 has not had training on tracheostomy care and had not completed the skills check. The Director of Staff Development and Infection Control stated that RN #2 did not have tracheostomy care training during orientation and received the training last week with skills check. Review of RN #2's tracheostomy training and skills check revealed it was dated 5/21/21 as completed. During an interview on 5/21/21 at 9:18 a.m. with the Director of Nursing (DON). S/he stated that s/he expected staff to follow the facility policy on tracheostomy care and guidelines for aseptic technique. During an interview on 5/21/21 at 9:20 a.m. with the Director of Staff Development and Infection Control. S/he stated that staff must use aseptic technique when performing tracheostomy care. 3. During an observation on 5/18/2021 at 11:58 a.m. CNA #5 was observed entering room [ROOM NUMBER] and exiting with Resident #19's water cup. CNA #5 opened the ice chest and used the ice scoop to fill the resident's cup with ice. When completed CNA #5 placed the ice scoop inside the ice chest for storage. CNA #5 entered room [ROOM NUMBER] and exited with Resident #50's water cup. CNA #5 opened the ice chest and used the ice scoop to fill the resident's cup with ice. When completed CNA #5 placed the ice scoop inside the ice chest for storage. Observation of the ice chest revealed that the ice scoop was stored in the ice chest, the hand of the ice scoop was touching the ice within the ice chest. CNA #5 stated that s/he left the ice scoop in the chest when s/he was filling the resident's cups, but s/he would take the scoop out and put it in a plastic bag when she was done. During an observation on 5/19/21 at 3:34 p.m. of the ice chest located in the nourishment room on the [NAME] Unit revealed the ice scoop was located in the ice chest, the ice chest was filled with ice and the handle of the scope was touching the ice. During an interview on 5/21/21 at 3:04 p.m. with the Director of Staff Development and Infection Control, s/he stated that staff were not to store the ice scoop in the ice chest. S/he stated that s/he would be ordering ice scoop holders to place on the outside of the ice chest. Observation on 5/18/21 at 12:11 p.m. revealed a Certified Nursing Assistant (CNA) passed ice on the [NAME] Unit. The CNA retrieved the cup from the resident's room, took the scoop laying on the ice in the ice chest and filled the cup with ice. The CNA then dropped the scoop back onto the ice, returned the cup with ice to the resident's room and then went to the next resident's room and repeated the process without washing her hands. Observation on 5/20/21 at 11:29 a.m. revealed a CNA passed ice to the residents on the [NAME] Unit. The CNA retrieved the cup from the resident's room, took the scoop laying on the ice in the ice chest and filled the cup. The CNA then dropped the scoop back onto the ice, returned the cup with ice to the resident's room and then went to the next resident's room and repeated the process without washing her hands. Observation on 5/21/21 at 2:02 p.m. revealed a CNA passed ice to the residents on the [NAME] Unit. The CNA retrieved the cup from the resident's room, removed the cup's lid, took the scoop laying on the ice in the ice chest and filled the cup. The CNA then dropped the scoop back onto the ice, placed the lid back on the cup and returned the cup with ice to the resident's room and then went to the next resident's room and repeated the process without washing her hands. 4. Review of Resident #41's clinical record revealed an admission date of 4/19/17 and the diagnoses included: Anoxic Brain Damage; Tracheostomy Status; Gastrostomy (g-tube) Status; Aphasia; and Cerebral Infarction. Review of Resident #41's Physician's Orders for May 2021 revealed: Trach care every shift with number (#) four (4) Disposable Trach and oxygen (O2) via trach at four (4) liters per minute (LPM). Review of Resident #41's Care Plan dated 3/25/21 listed the intervention for trach care every shift. Observation on 5/20/21 at 11:30 a.m. revealed Licensed Practical Nurse (LPN) #4 provided trach care while wearing a mask but not a face shield. Observation revealed LPN #4 removed the old trach dressing without gloves on, washed her hands, opened the trach kit, removed the barrier and package of gloves and placed the supplies on the overbed table. The nurse then turned over the trach container to remove the additional items out of the kit. The nurse then donned gloves, removed the inner cannula and placed it in the peroxide. LPN #4 then used the brush to clean the white plastic trach holder and q tips to clean under the holder. The nurse tried to clean the cannula by swishing it back and forth in the peroxide, then into the sterile water, then back into the peroxide and then tapping it on the end of the cannula multiple times, and then repeated this process multiple times trying to get the yellow mucus out of the cannula. The nurse then went and opened the cabinet looking for another trach kit. LPN #4 was unable to find one and then went back to attempting to clean the cannula with the same gloved hands. The nurse rolled up a four by four gauze and attempted to insert it into the cannula without success. LPN #4 then stated s/he needed to get another trach kit and replaced the cannula back into the opening without changing her gloves. LPN #4 then came back to the room, did not wash her hands, and opened the trach kit, removed the barrier and the gloves and then turned over the trach kit emptying the additional supplies out of the kit. The nurse then donned gloves, cleansed the inner cannula, and reinserted it in the trach. Interview with the Director of Nursing (DON) on 5/21/21 at 9:18 a.m. revealed the staff should use aseptic technique when providing trach care.