**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure: *Proper infection control practices had been followed for cleaning and storage for two of two sampled residents (9 and 25) who required respiratory devices (Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open) and a nebulizer), had appropriate cleaning and storage. *One of one sampled resident (25) receiving oxygen at night had a current physician order for use of a CPAP machine, and was care planned. Findings include: 1. Observation and interview on 5/5/25 at 1:39 p.m. and 1:57 p.m. with resident 9 in his room revealed: *There was a nebulizer machine (a machine that converts liquid medication into an inhalable mist) on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. *He reached down and shut off that nebulizer machine, then turned it back on when the surveyor stated she would return. -He kept the nebulizer machine on the floor, so it was easy for him to reach, and it was quieter there. *He stated that the nurse would put the medication in the nebulizer mask, and he would administer his nebulizer treatment. *He hung the nebulizer mask from the tack on his calendar between the four nebulizer treatments he received each day. -He was unsure when the nebulizer mask would need to be cleaned, but thought the nurse did that once a day. Observation and interview on 5/6/25 at 11:20 a.m. with resident 9 in his room during the administration of a nebulizer treatment by licensed practical nurse (LPN) F revealed: *After the completion of the nebulizer administration, while LPN F rinsed the nebulizer mask out in the sink, resident 9 stated he usually did not rinse out his mask after he completed his nebulizer treatments, and he would just hang it on here as he pointed to a tack on the wall beside his recliner. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included chronic obstructive pulmonary disease, cancer of his right lung, pulmonary embolism, and bronchitis. *He had a Brief Interview of Mental Status (BIMS) assessment score of 11, which indicated he was moderately cognitively impaired. *A 5/1/25 physician's order for Ipratropium-Albuterol Inhalation Solution [an inhaled medication to ease breathing by opening the airway in the lungs] 0.5-2.5 (3) MG/3ML [milliliter] 1 vial inhale orally four times a day for bronchitis for 5 Days. *A 5/6/25 physician's order for Ipratropium-Albuterol Inhalation Solution .0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for bronchitis. *There was no documentation in his EMR that his nebulizer mask and tubing were to have been cleaned, by whom, or how often that should have been completed. 2. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *He was lying in bed with his eyes open and a CPAP (a machine that uses air pressure to keep breathing airways open) on. *He stated he had worn his CPAP for several years and he brought it into the facility from home when he was admitted . Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *He had diagnoses of other forms of dyspnea (difficulty breathing), and obstructive sleep apnea (intermittent airflow blockage during sleep). *There was no physician's order for the use of his CPAP in his EMR. *There was no documentation in his EMR that indicated his CPAP mask and tubing was being cleaned. *His initial baseline care plan did not indicate the use of the CPAP. *His current care plan did not address his respiratory diagnoses or the use of his CPAP machine. Follow up interview on 5/7/25 at 9:40 a.m. with resident 25 in his room revealed: *The nurses would empty and refill his CPAP reservoir with distilled water every night and as needed. *No one had cleaned his CPAP tubing or mask that he was aware of since admission. 3. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I revealed: *Nebulizer delivery devices were to be replaced weekly on Fridays by the night nurse. *The replacement of the devices was to be charted in the resident's medication administration record (MAR). *Nebulizer deliver devices were to be rinsed out and cleaned after each use by running them under tap water. *The mask and tubing of the CPAP machine were to be cleaned weekly by the night nurse with a vinegar and water solution. *The cleaning of respiratory devices were to be charted in the resident's MAR. *She was unsure of the exact process used for the cleaning of the CPAP mask and tubing by nights since resident 25 wore his CPAP mask at night. 4. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *Nebulizer delivery devices were to be replaced weekly and that was to be documented in the resident's MAR. *It was her expectation the nebulizer deliver devices were to be disassembled, rinsed out with tap water, and left to dry on a towel after every use for infection control purposes. *The nebulizer machine was to be stored in a location such as on a bedside table not in the floor. *The mask and the tubing of the CPAP machine was to be cleaned weekly with a vinegar and water mixture by the night nurse. *The cleaning of the CPAP machine was to be documented in the resident's MAR. *She was not aware there was not a physician's order for resident 25's CPAP use. *She was not aware the cleaning of the CPAP tubing and mask was not being documented in resident 12's MAR. *She was not aware resident 12's care plan did not address his CPAP use. *She would expect there to be a physician's order for the CPAP, and the cleaning of the CPAP was documented in the EMR. *She agreed the some of the facility policies did not reflect the provider's processes and practices, and some of the policies, including those related to nebulizers, were not consistent with each other. 5. Review of the provider's June 2023 Cleaning of Durable Medical and Therapy Equipment policy revealed: *CPAP: 1) Clean tubing and mask with warm water and soap, rinse well, and hang to dry daily. *Nebulizer Treatments: Cleaning must be completed after each use. -1) Take nebulizer apart by removing tubing and setting aside. -2) Remove mouthpiece or mask and medicine cup from the top, -3) Rinse with sterile or distilled water and place on clean dry surface (be sure to use a barrier such as a paper towel) to dry after each use. -4) Let pieces air dry. Review of the provider's January 2018 Specific Medication Administration Procedures revealed: *When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup. *Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations or: -1) Wash pieces (except tubing) with warm, soapy water daily. Rinse with hot water. Allow to air dry completely on paper towel. -2) [Once a week/three times a week/daily], disinfect the equipment by: --a. [Using a Microsteam bag in the microwave for time recommended on bag], OR --b. [Soaking for 5 minutes in 70% isopropyl alcohol and then rinse with sterile water]. *When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. *Change equipment and tubing every [seven days].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Observation and interview on 5/5/25 at 4:07 p.m. with resident 7 in his room revealed: *He was sitting in his recliner. *He was not sure if he had attended any counseling sessions. *His biggest concern at that time was the food he was being served. Review of resident 7's EMR revealed: *He was admitted on [DATE]. *His 3/31/25 BIMS assessment score was 11, which indicated he was moderately cognitively impaired. *His diagnoses included: -Post-traumatic stress disorder, unspecified. -Delirium due to known physiological condition. -Personal history of other mental and behavioral disorder. -Major depressive disorder, recurrent, severe with psychotic symptoms. Review of resident 24's 4/1/25 care plan revealed: *He had a focus area of, an ADL [activities of daily living] self-care performance deficit r/t [related to] delirium/depression/PTSD. *A goal to maintain current level of function through the next review. *No interventions to suggest how to address any issues that may arise from his PTSD. 7. Interview on 5/6/25 at 4:36 p.m. with LPN/SSD D regarding resident 7's PTSD diagnoses revealed: *If a resident had a PTSD diagnosis, they were set up with an appointment with behavioral health services. *PTSD was entered into the resident's care plan. *She was not aware of any interventions that would directly address a resident's PTSD. *She confirmed she had not completed a trauma-informed care assessment for resident 7. 8. Review of the provider's March 2025 Facility Assessment policy revealed: *Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. *Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information and are aware of preferences. A policy for trauma informed care was requested on 5/7/25 from administrator B but one was not provided by the end of the survey on 5/8/25. Based on observation, interview, record review, and policy review, the provider failed to assess two of two sampled residents (7 and 14) who had a diagnosis of post-traumatic stress disorder (PTSD) for their potential needs and interventions relating to trauma. Findings include: 1. Observation on 5/5/25 at 12:59 p.m. of resident 12's room revealed: *He had a sign on his door that read, Do Not Disturb. *He had military décor in his room. Review of resident 12's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *His diagnoses included anxiety disorder, major depressive disorder, hallucinations, post-traumatic stress disorder (PTSD), and vascular dementia with psychotic disturbance, mood disturbance, and anxiety. *He was a military veteran. *He had a history of suicidal thoughts, chemical dependency, visual hallucinations that were distressing to him. *He had a history of chemical dependency. *His care plan did not address behaviors, and triggers, or interventions related to his diagnoses. *There was an incident on 4/10/25 where resident 14 struck [resident 20] in the left cheek with a closed fist. *It was documented in the provider's investigation, Resident 14 stated that resident 20 had opened his door and peeked in and then shut the door. [Resident 14] went out and asked [resident 20] what he wanted. [Resident 20] did not answer [resident 14] and this made him angry so he punched him. 2. Interview on 5/6/25 at 4:22 p.m. with director of nursing (DON) C revealed the provider did not have a policy for addressing residents with a history of trauma or trauma informed care. 3. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I revealed: *Resident 14 had PTSD related to his military service. *She indicated resident 14 could get worked up at times when he thought people were stealing from him. *She was aware of an incident when resident 14 struck another resident in the face with a closed fist. *She indicated staff would talk to him after the incidents or times when he was worked up and he would calm. 4. Interview on 5/8/25 at 8:59 a.m. with LPN/social service designee (SSD) D revealed: *There were no assessments that were being completed for residents related to trauma informed care. -She asked about trauma on a resident's admission to the facility and made note. --There was no documentation able to be located regarding that in resident 14's EMR. *Resident 14's care plan had a focus area of sees mental health provider from [another town] for mental health needs with an intervention that stated, Attend appointments as scheduled and PRN [as needed]. *She was unable to locate documentation of resident 14 having attended appointments with the identified mental health provider. *She stated behaviors, triggers, and interventions for the behaviors should have been identified in the resident's care plan for staff to be able to meet their needs. *She verified there were no behaviors or interventions related to resident 14's PTSD, anxiety, or hallucination diagnoses in his care plan. 5. Interview on 5/8/25 at 11:53 a.m. with director of nursing (DON) C revealed: *Resident 12 had not seen a mental health provider since early 2024. *He had not and was not seeing a mental health provider on a scheduled or as needed basis as his care plan indicated.

Based on observation, interview, and policy review the provider failed to follow acceptable food safety practices by not having ensured that food packages were dated when opened and outdated food items were discarded from inventory in one of one observed kitchen. Findings include: 1. Observation on 5/5/25 at 1:03 p.m. of the dry food storage room revealed: *One opened container of [NAME] Crispies cereal with no date on it. *One opened container of Raisin Bran cereal with no date on it. 2. Observation on 5/5/25 at 1:27 p.m. of the walk-in refrigerator revealed: *One carton of Vanilla Boost Glucose Control supplement with a use-by date of January 3, 2025. *One opened package of shredded low moisture mozzarella cheese with a best by date of April 19, 2025. *The mozzarella cheese had condensed into quarter-sized balls of cheese. 3. Interview on 5/5/25 at 1:34 p.m. with dietary manager E regarding opened and expired food items revealed: *He was not aware of the unmarked opened food containers or the outdated food items. *It was his expectation that containers of food would be dated when opened, and food items would be used or discarded before the use-by date. *His expectation was that all dietary staff would monitor food items for food items that were past the use by date or expired. *He checked used by dates when the weekly food truck delivery arrived. 4. Review of the provider's 5/5/25 revised Expired Food policy revealed: *Food products will be inspected on a regular basis to ensure that any products that are expired or near expiration will be identified and reported to the DM for further instructions. *All products will be inspected weekly by Dietary Personnel on Wednesday before the arrival of the food truck. *All items that are expired will be labeled (Do not use/Do not discard). *All staff must follow FIFO (First In First Out) and inspect the expiration date on all products that are needed for use before they are used in the operation. Review of the provider's 10/20/24 revised Storage of food opened in the storeroom or preparation area policy revealed: *To make sure all items that are opened in the storeroom or main production area are covered, labeled and dated properly. *1. Date the container when opened. *2. Reseal the container. *3. If the container cannot be resealed, you can place it in a Tupperware container with a tight lid and/or a zip lock bag if possible. Label and date the product.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure: *Four of four sampled residents (3, 8, 9, and 18) had been assessed to determine their ability to safely self-administer medications. *Three of four sampled residents (3, 9, and 18) had a physician's orders to self-administer those medications as directed in the provider's policy. Findings Include: 1. Observation and interview on [DATE] at 1:39 p.m. and 1:57 p.m. with resident 9 in his room revealed: *There was a nebulizer machine (a machine that converts liquid medication into an inhalable mist) on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. *He reached down and shut off that nebulizer machine, then turned it back on when the surveyor stated she would return. -He kept the nebulizer machine on the floor, so it was easy for him to reach, and it was quieter there. *He stated that the nurse would put the medication in the nebulizer mask, and he would administer his nebulizer treatment. *He hung the nebulizer mask from the tack on his calendar between the four nebulizer treatments he received each day. -He was unsure when the nebulizer mask would need to be cleaned, but thought the nurse did that once a day. *There were two unmarked clear plastic medication cups on his bedside stand, one containing a green gel and the other a light-yellow ointment. -He stated that the light-yellow ointment was a thick lotion for his feet. It would be nice if the staff would rub it in. That cream is as thick as axle grease. -The green gel was Biofreeze (pain-relieving gel) for when the therapist came and worked on his neck. *The nurse had left those creams there for him to use when he needed them. *He stated that the nurse also brought his antacid medication and left that in a small cup next to his bed for him to take when he woke up each morning. -He had been angry that the nurse would wake him up and had told the nurse he wanted to refuse that medication so he could sleep. --The nurse now left the medication on his nightstand each morning and did not wake him. Observation on [DATE] at 4:04 p.m. with resident 9 in his room revealed: *The nebulizer machine was on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. Observation and interview on [DATE] at 11:20 a.m. with resident 9 in his room during the administration of a nebulizer treatment by licensed practical nurse (LPN) F revealed: *He had a bottle of Neomycin-Polymyxin otic solution (antibiotic ear drops) on the shelf above his sink that expired in [DATE]. *There were two clear plastic medication cups on his bedside stand that contained a light-yellow ointment and were not labeled with a resident's name or the cups' contents. *After the completion of the nebulizer administration, while LPN F rinsed the nebulizer mask out in the sink, resident 9 stated he usually did not rinse out his mask after he completed his nebulizer treatments, and he would just hang it on here as he pointed to a tack on the wall beside his recliner. Observation and interview on [DATE] at 4:25 p.m. with resident 9 regarding the antibiotic ear drops in his room revealed: *The drops were from when he had an ear infection when he lived at home, a couple of years ago. *He stated he now puts a couple of drops in his ears when they itch. *He was unaware that they had expired. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview of Mental Status (BIMS) assessment score of 11, which indicated he was moderately cognitively impaired. *A [DATE] physician's order for Omeprazole [an antacid] Oral Capsule Delayed Release 20 MG [milligrams]. Give 1 capsule by mouth in the morning for esophageal varices, was scheduled for administration at 6:00 a.m. every day. *A [DATE] physician's order for Ipratropium-Albuterol Inhalation Solution [an inhaled medication to ease breathing by opening the airway in the lungs] 0.5-2.5 (3) MG/3ML [milliliter] 1 vial inhale orally four times a day for bronchitis for 5 Days. *A [DATE] physician's order for Biofreeze External Cream 10% . Apply to [the] affected area topically every 6 hours as needed for Pain. Apply to [the] affected area up to QID [four times a day] PRN [as needed]. *A [DATE] physician's order for Aquaphor External Ointment Apply to dry skn [skin] topically as needed for Bilateral [both] feet. Apply BID [two times a day] PRN. *There was no physician's order for his self-administration of medications. *There was no documentation that he had been assessed for his ability to safely self-administer medications. *His care plan did not address self-administration of medications. Observation and interview on [DATE] at 4:38 p.m. with LPN I regarding resident 9's medication orders revealed: *Resident 9 did not have an order for the antibiotic ear drops. -She was unaware that those drops were in his room and thought his family would have brought them to him from home. *She confirmed that the light-yellow ointment was Aquaphor and the green gel was Biofreeze. *She confirmed that resident 9 did not have a physician's order for self-medication administration for any of his medications. *She stated, Nobody in the facility has a self-medication order. *She had not left medications at resident 9's bedside. *She confirmed that he would need a physician's order for his self-administration of the Biofreeze, antibiotic ear drops, and nebulizer treatments. -She did not think he needed a physician's order for the Aquaphor. 2. Observation and interview on [DATE] at 9:28 a.m. with resident 8 in his room revealed: *There was a bottle of cream with a prescription label on it on the table to the left of his chair and a bottle of powder with a prescription label on it on the shelf above his sink. *He stated he put the cream on his feet twice a day and used the powder about three times a week when he got himself washed and dressed in the morning. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. *A [DATE] physician's order for Nystatin Powder . Apply to groin folds topically two times a day .MAY KEEP NYSTATIN IN HIS ROOM. *A [DATE] physician's order for [NAME] External Lotion 0.5-0.5% . Apply to feet & legs topically two times a day for Dry skin MAY KEEP [NAME] IN HIS ROOM. *There was no documentation that he was assessed for his ability to safely self-administer medications. *His care plan did not address his self-administration of medications Interview on [DATE] at 4:38 p.m. with LPN I regarding resident 8's medications revealed she confirmed that resident 8 self-administered the above-listed medications, and that he had physician's orders to keep his [NAME] lotion and nystatin powder at his bedside. 3. Observation and interview on [DATE] at 1:26 p.m. with resident 3 in her room revealed: *There was an assembled nebulizer mask draped over a nebulizer machine on her bedside stand. *She stated she rinsed out the nebulizer mask in the sink after she completed her nebulizer administration, reassembled the mask and then laid it on her bedside table. *She verified that she administered her own nebulizer treatment after the nurse brought in the nebulizer medication and set up the treatment. Review of resident 3's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated she was cognitively intact. *She had a [DATE] physician's order for Albuterol Sulfate Inhalation Nebulization Solutions 2.5 MG/0.5 ML [an inhaled medication to ease breathing by opening the airway in the lungs] (Albuterol Sulfate) 1 vial inhale orally three times a day and every 4 hours as needed for SOB [shortness of breath]. *There was no physician's order for her self-administration of medications. *There was no documentation that she was assessed for her ability to safely self-administer medications. *Her care plan did not address her self-administration of medications. 4. Observation on [DATE] at 2:53 p.m. of resident 18's room revealed a partial container of Vicks Vapor Rub medicated ointment was on the arm of his recliner. Review of resident 18's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 8, which indicated he was moderately cognitively impaired. *He did not have a physician's order for the Vicks Vapor Rub medicated ointment. *He did not have a physician's order for his self-administration of medications. *There was no documentation that she was assessed for his ability to safely self-administer medications. *His care plan did not address his self-administration of medications or the storage of medications in his room. 5. Interview on [DATE] at 2:47 p.m. with LPN I revealed she stated: *There were no residents who were to self-administer medications in the facility. *For a resident to self-administer medications it would have required a physician's order for medication self-administration. Continued interview on [DATE] at 2:55 p.m. with LPN I regarding the Vicks Vapor Rub medicated ointment in resident 18's room revealed: *Vicks Vapor Rub was a medicated ointment and it would have required a physician's order for administration. *Resident 18 did not have a physician's order for Vicks Vapor Rub or the self-administration of it. *He did not have a medication self-administration assessment documented in his EMR to support he was assessed for his ability to safely self-administer medication. 6. Interview on [DATE] at 9:21 a.m. with director of nursing (DON) C revealed: *She would consider medications in a resident's room that the resident was taking or applying independently, as self-administration of medication. *She expected no medications to be stored at a resident's bedside without a physician's order for self-administration. *It was their policy only nebulizer treatments were assessed for self-administration. *She was aware that resident 9 had been self-administering his nebulizer treatment, had antibiotic ear drops and prescribed creams in his room, and that a nurse had left his omeprazole at his bedside without waking him. -She verified that resident 9 did not have a physician's order or assessment for self-administration of medications. *She was aware that resident 8 had a lotion and a powder at his bedside because he had requested those, and they had obtained an order from his physician. *They had completed a self-administration assessment in 2022 when resident 8 had self-administered his nebulizers. -She confirmed there was no self-administration assessment done for resident 8's lotions or powders to ensure he was safe to self-administer those. *She verified that resident 3 did not have a physician's order or assessment for self-administration of medications. *She was unaware that resident 18 had Vicks Vapor Rub medicated ointment in his room. -She verified resident 18 did not have a physician's order or assessment for self-administration of medications. *She stated there were residents in the facility with cognitive impairment who wandered into other resident rooms. *One of the cognitively impaired residents who wandered into residents' rooms had a history of rummaging through items in other residents' rooms. *She agreed that some of their policies did not reflect their processes, and some of those policies, including those related to nebulizers, were inconsistent with other policies they had. *She confirmed there were no residents who had been assessed for self-administration of medication. *She confirmed there were no residents who had a physician's order for self-admininstration. 7. Review of the provider's [DATE] Self-Administration of Medications policy revealed: *In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. *If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. *For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. *The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered. *If the resident demonstrates the ability to self-administer medications, a further assessment of the safety of bedside medication storage is conducted. *Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. Review of the provider's [DATE] Self-Administration of Medications policy revealed: *To ensure doctor orders are followed and correctly documented, ensuring the highest level of care is provided . *The only Medications that residents . will [be] able to be self-administer[ed] are inhaled medications. Refer to self-Administration of Nebulizer Treatments. for more details. Review of the provider's [DATE] Self-Administration of Nebulizer Treatments policy revealed: * .Inhaled medications may be taken without supervision after a nurse or CMA [certified medication aide] setup, a doctor order [is] on file, and Self-Administration of Nebulizer Treatments Assessment is completed. *Resident must be evaluated by nursing for the appropriateness of their ability to self-administer Nebulizer Treatments. Assessments will be completed quarterly based on MDS scheduling. Nursing is responsible for obtaining doctor order, care planning the self-administration of inhaled meds along with any restrictions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation and interview on 5/6/25 at 8:55 a.m. with resident 79 in her room revealed she: *Could not remember the exact date she was admitted , but she knew it was in March 2025. *Had been in and out of the hospital at least two times since she was admitted due to blood loss. *Did not know what a care plan was. Review of resident 79's EMR on 5/7/25 revealed: *She was admitted on [DATE]. *Her 3/10/25 BIMS assessment score was 10, which indicated she was moderately cognitively impaired. *Her baseline care plan had been initiated on 3/3/25 but was not completed. *The baseline care plan was labeled 'Errors in the EMR. *There were no progress notes that indicated a baseline care plan was reviewed or given to the resident or her representative. Based on record review, interview, observation, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for four of four recently admitted sampled residents (9, 19, 25, and 79) within 48 hours of their admission to the facility. Findings include: 1. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated he was moderately cognitively impaired. *His baseline care plan was initiated on 12/2/24. *The section Signature and Representative and the date had been left blank. *There was no documentation that indicated the care plan was reviewed with him, his representative, or that he had been provided or offered a copy of his baseline care plan within 48 hours of his admission. Interview on 5/6/25 at 4:25 p.m. with resident 9 regarding his care plan revealed he did not recall if anyone had reviewed his care plan or his medications with him in the first 48 hours after he had been admitted to the facility. 2. Review of resident 19's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 8, which indicated she was moderately cognitively impaired. *Her baseline care plan was initiated on 4/22/24 and indicated it was In Progress. *The following sections were incomplete: -Active diagnoses contributing to admission had been left blank. -Signature and Representative and the date had been left blank. -Signatures of Staff Completing the Baseline Care Plan had been left blank. *There was no documentation that indicated the care plan was reviewed with her, her representative, or that she or her representative had been provided or offered a copy of her baseline care plan within 48 hours of her admission. Interview on 5/7/25 at 2:49 p.m. with resident 19 regarding her care plan revealed she did not recall if anyone had reviewed her care plan or her medications with her in the first 48 hours after she had been admitted to the facility. 4. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed he: *Was lying in bed with his eyes open and a CPAP (a machine that uses air pressure to keep breathing airways open) on. *Had a black equalizer boot (a boot used to improve stability and decreased pain and swelling) on his right leg. *Had been admitted to the facility a few weeks ago after he broke his right ankle *Stated he was at the facility to receive therapy services and planned to return home after his therapy was completed. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *His baseline care plan was initiated on 4/8/25. *His baseline care plan did not indicate his use of a CPAP machine. *His baseline care plan did not contain a signature or date that would indicate the care plan was reviewed with him, if he was offered or provided a copy of his baseline care plan or when that may have occurred. Follow-up interview on 5/7/25 at 9:42 a.m. with resident 25 in his room revealed he did not: *Recall reviewing his plan of care with a staff member. *Receive or was offered a copy of his care plan. 5. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C regarding residents' baseline care plans revealed: *The baseline care plan was initiated at the time of resident's admission. *She reviewed the baseline care plan with the resident or resident representative on admission. *She offered the resident or the resident representative a copy of the baseline care plan but stated they rarely accepted it. *She verified resident 19, 25, and 79's baseline care plans were incomplete and did not contain documentation to support that those residents' care plans had been reviewed with the residents or their representative or that a copy of the baseline care plans were offered to them. 6. Review of the provider's February 2025 Care Planning Process policy revealed: *Using an interdisciplinary approach, each resident will have an individualized plan of care which addresses the resident's current care needs and severity of condition, impairment, disability, or disease. *An interim plan of care [baseline care plan] will be developed by the admission nurse within 24 hours after admission utilizing the resident profile. Specific care needs will be transferred to the CNA pocket care plan. -The provider policy did not contain that the baseline care plan was to be reviewed with the resident or resident representative within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation and interview on 5/5/25 at 4:07 p.m. with resident 7 in his room revealed: *He was sitting in his recliner. *He was not sure if he had been offered counseling sessions. *His biggest concern at that time was the food he was being served. Review of resident 7's EMR revealed: *He was admitted on [DATE]. *His 3/31/25 BIMS assessment score was 11, which indicated he was moderately cognitively impaired. *His diagnoses included: -Post-traumatic stress disorder (PTSD), unspecified. -Delirium due to a known physiological condition. -Personal history of other mental and behavioral disorder. -Major depressive disorder, recurrent, severe with psychotic symptoms. Review of resident 7's 4/1/25 care plan revealed: *He had a focus area of, an ADL [activities of daily living] self-care performance deficit r/t [related t]) delirium/depression/PTSD. *The goal for the area was to maintain his current level of function through the next review. *There were no interventions included in his care plan to suggest how to address issues that may arise from his PTSD. Interview on 5/6/25 at 4:36 p.m. with licensed LPN/SSD D regarding resident 7 and residents with a PTSD diagnosis revealed: *If a resident had a PTSD diagnosis, they were to be set up with an appointment with behavioral health services. *PTSD was to be entered into the care plan. *She was not aware of any interventions entered into resident 7's care plan for his PTSD that would educate staff to help him cope or to prevent potential triggers for retraumatization. Based on observation, record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for seven of twelve sampled residents (7, 8, 9, 14, 17, 19, and 25). Findings include: 1. Observation and interview on 5/5/25 at 1:39 p.m., 1:57 p.m. and again at 4:04 p.m. with resident 9 in his room revealed: *There was a large table that took up most of his room with a puzzle on it. He stated he spent much of his time working on puzzles. -He had completed several puzzles that were hung throughout the facility. *He had been admitted from [name of institution] and would be transferred to another facility. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated he was moderately cognitively impaired. *There was no documentation in his care plan that indicated his activity interests related to puzzles or his discharge plans. 2. Observations and interview on 5/5/25 at 2:35 p.m. and 5:22 p.m. with resident 17 and her husband revealed: *Resident 17 shared a room with her husband, who was an assisted living resident, and they sat in separate recliners in their room. *Resident 17 had an electric recliner that she was unable to operate independently. *Resident 17's husband stated that only he and the staff operated the resident's electric recliner when she would rest to elevate her feet. -Sometimes he needed to elevate the recliner so she could get up when it was time to go to dinner. *She did not attempt to operate the recliner on her own. *Resident 17 did not respond to any questions. Interview on 5/5/25 at 5:01 p.m. with certified nursing assistant (CNA) M regarding resident 17 revealed: *At times, she would sit in either recliner in her room. *She would follow simple directions, but did not respond to any questions asked of her. Observation and interview on 5/5/25 at 8:34 a.m. with resident 17 and physical therapy assistant (PTA) P revealed: *Resident 17 followed simple commands, walked with PTA P holding her hand, and her speech was unintelligible. *PTA P stated that resident 17 was on a maintenance and positioning program that included therapy twice a week and elevating her feet in her recliner. *PTA P had educated the staff that resident 17 was to sit in her recliner for half an hour twice a day with her feet elevated. *Resident 17 was unable to operate the remote and was to sit in her recliner with her feet elevated only when her husband was in the room. *She had never seen resident 19 touch the recliner remote. Interview on 5/7/25 at 4:07 p.m. with CNA L revealed: *Resident 17 sat with her feet elevated in the recliner only when her husband was in the room because it was safer. *She knew what care each resident required because it was in their care plan in the EMR. -She was unsure if resident 17's use of the recliner or positioning program would be included in her care plan. Review of resident 17's EMR revealed: *She was admitted on [DATE]. *Her 3/17/25 Minimum Data Set (MDS) indicated she was rarely understood or able to understand others and was severely cognitively impaired. *There was no documentation in her care plan that indicated her participation in a therapy maintenance and positioning program, or that her feet were to be elevated while in her recliner with her husband's supervision. Interview and review of resident 17's positioning program on 5/8/25 at 9:15 a.m. with director of nursing (DON) C revealed: *She was not aware that resident 17 was on a positioning program provided by PTA P. *That positioning program included the instruction to Please ensure pt [resident 17] is elevating LE's [lower extremities] in recliner at least 2X [two times] per day for edema management. Once in the am [morning] and once in PM [afternoon]. Spouse is also educated and showed how to work recliner if she does try to get up. *She expected that the positioning program and the instruction for elevating her lower extremities in the recliner to be included in resident 17's care plan. 3. Observations and interview on 5/5/25 at 2:32 p.m. and again on 5/6/25 at 2:06 p.m. with resident 19 in her room revealed: *There were signs in her room to provide reminders on where her snacks were located. *Her hands were tremoring and she rubbed her fingers together. *She answered questions with brief responses. *She was lying on her bed, and her legs were in constant movement. *There were no bed rails on her bed. Observations on 5/5/25 at 5:27 p.m. and again on 5/6/25 at 7:33 a.m. with resident 19 in the dining room revealed: *She was seated at the table in a dining room chair. *She held tightly to the chair and would scoot forward and back in that chair. *At times, she would stand and then return to sitting. *She appeared restless and anxious. *Her upper body was stiff, and her arms appeared tense. Review of resident 19's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 3, which indicated she was severely cognitively impaired. *Her diagnoses included Wernicke's Encephalopathy (a neurological condition caused by lack of vitamin B1), anxiety disorder, amnestic disorder (memory loss), and drug-induced subacute dyskinesia (a movement disorder caused by certain medications). *Resident 19's progress notes indicated: -On 4/28/24, Resident 19 .has been anxious since [the] beginning of [the] shift. -On 6/24/24, Resident brought up to [the] nurse station. Crying and shaking . PRN [as needed] Ativan [a medication for anxiety] given. -On 8/2/24, Due to her being upset, pacing, and repeatedly questioning things [she] was given Lorazepam [a medication for anxiety] again this evening. -On 10/30/24, Unfortunately her anxiety is keeping her from being distracted/redirected. She was given a prn [PRN] Ativan before lunch and [it] is not effective in managing symptoms at this time. Update provided to [physician]. -On 12/17/24, She is pacing about the facility in an anxious state. -On 2/25/25, Resident noted to be pacing up and down the hallways .PRN lorazepam given. -On 4/7/25, she is up much of the night asking for medications to help her sleep . Current PRNs are not very effective. *Her care plan indicated that resident 19 used bilateral top quarter rails to enable her independence with bed mobility, repositioning, and transfers in and out of bed, which was initiated on 5/1/24. *There was no documentation in her care plan that indicated current or past non-pharmacological interventions that had been tried to address resident 19's anxiety symptoms. Interview on 5/8/25 at 7:43 a.m. with LPN/social service designee (SSD) D revealed: *She was aware of resident 19's history of anxiety, pacing, and crying, and confirmed that those behaviors were still present. *She completed sections of the care plan related to the resident's code status, discharge to home planning, their religion, and who they received mental health services from. *She did not complete sections related to the resident's mood or behavior; she thought nursing had completed that section. Interview on 5/8/25 at 8:37 a.m. with DON C and LPN/SSD D regarding resident 19's care plan revealed: *LPN/SSD D completed bed rail assessments and care planned the use of the bed rails. *Resident 19 had been assessed for the use of bed rails, had bed rails on her bed, and then had requested that the bed rails be removed. *The use of bed rails was not removed from her care plan because resident 19 often changed her mind and forgot what she had requested, and she may want them back on the bed in the future. *DON C confirmed that resident 19's care plan should have been updated when the bed rails had been removed. *DON C confirmed that resident 19's care plan did not reflect her current care needs and interventions used to manage her anxiety, pacing, and crying, or the status of the mental health services they had been working to implement. 4. Observation and interview on 5/7/25 at 9:28 a.m. with resident 8 in his room revealed: *There was a bottle of cream with a prescription label on it on the table to the left of his chair, and a bottle of powder with a prescription label on it on the shelf above his sink. *He stated he put the cream on his feet twice a day and used the powder about three times a week when he got himself washed and dressed in the morning. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. *A 3/4/25 physician's order for Nystatin Powder . Apply to groin folds topically two times a day .MAY KEEP NYSTATIN IN HIS ROOM. *A 3/4/25 physician's order for [NAME] External Lotion 0.5-0.5% . Apply to feet & legs topically two times a day for Dry skin MAY KEEP [NAME] IN HIS ROOM. *There was no documentation in his care plan that addressed his self-administration of those medications. Interview on 5/6/25 at 4:38 p.m. with LPN I regarding resident 8's self-administration of medications revealed she was unsure if that should have been included in his care plan. 6. Observation on 5/5/25 at 12:59 p.m. of resident 14's room revealed a sign on his door that read, Do Not Disturb. Review of resident 12's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *His diagnoses included anxiety disorder, major depressive disorder, hallucinations, post-traumatic stress disorder (PTSD), and vascular dementia with psychotic disturbance, mood disturbance, and anxiety. *He was a military service veteran. *There was a focus area in resident 14's care plan that stated resident 14, became angry with another resident and struck him in the left cheek with a closed fist. [Resident 14] stated he got angry when he asked this resident a question and he didn't respond to him. -Interventions for this focus area were, Staff will monitor [resident 14's] and the other resident's whereabouts in the dining room. Writer explained to [resident 14] that he is not allowed to touch anyone else. [Resident 14] voiced understanding. *His care plan did not address his behaviors, triggers, or interventions related to his diagnoses. *There was no information in the care plan related to the Do Not Disturb sign that was posted on the resident's door. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I revealed: *Staff utilized pocket care plans, the communication binder, and resident care plans to determine the care that each resident required. *She verified the pocket care plans were currently not up to date and did not include some of the more recently admitted residents and their needs. *She indicated resident 14 could get worked up at times when he thought people were stealing from him. *She was aware of an incident when resident 14 struck another resident in the face with a closed fist. *She indicated staff would talk to him after the incidents or at times when he was worked up, and he would calm. Interview on 5/8/25 at 8:59 a.m. with LPN/SSD D revealed: *She verified resident 14 had an altercation with another resident and had struck another resident in the face with a closed fist. *Resident 14's care plan had a focus area of sees mental health provider from [a nearby town] for mental health needs with an intervention that stated, Attend appointments as scheduled and PRN [as needed]. *She stated behaviors, triggers, and interventions for residents' behaviors should have been identified in their care plan. *She verified there were no behaviors or interventions related to resident 14's PTSD, anxiety, or hallucination diagnoses in his care plan. Interview on 5/8/25 at 11:53 a.m. with DON C revealed: *Resident 14 had not seen a mental health provider since early 2024. *He had not and was not seeing a mental health provider in the town indicated on his care plan on a scheduled or as needed basis. 7. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *He was lying in bed with his eyes open and a CPAP (a machine that uses air pressure to keep breathing airways open) on. *He stated he had worn his CPAP for several years and he had brought it into the facility from home when he was admitted . Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *He had diagnoses of other forms of dyspnea (difficulty breathing), and obstructive sleep apnea (intermittent airflow blockage during sleep). *His care plan did not address his respiratory diagnoses or the use of his CPAP machine. 8. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *Care plans could be updated by the direct resident care nurses, the social service designee, the Minimum Data Set (MDS) nurse, and herself. *She indicated most of the residents' care plan updates were completed by the MDS nurse. *She expected residents' care plans to be updated quarterly, annually, with a resident's significant change and any time there was a change in the care for the resident. *The residents' care plans did not reflect the current care needs and interventions that had been implemented or needed to meet those needs. *The provider had not completed any formal audits of residents' care plans but she and the MDS nurse reviewed resident care plans weekly for residents scheduled to have their quarterly or annual MDS assessments completed. 9. Review of the provider's updated February 2025 Care Planning Process revealed: *To define the personnel's responsibility in initiating and maintaining the resident's care plan. *To ensure a comprehensive, individualized plan of care for each resident. *Using an interdisciplinary approach, each resident will have an individualized plan of care which addresses the resident's current care needs and severity of condition, impairment, disability, or disease. Review of the provider's March 2025 Facility Assessment policy revealed Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information and are aware of preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the provider failed to ensure: *A physician-ordered Abnormal Involuntary Movement Scale (AIMS) assessment was completed and the results were communicated for one of one sampled resident (19) who received an antipsychotic medication. *The physician was notified of one of one sampled residents' (25) insulin having been held related to low blood sugars. Findings include: 1. Observations and interview on 5/5/25 at 2:32 p.m. and again on 5/6/25 at 2:06 p.m. with resident 19 in her room revealed: *There was a tremoring of both of her hands, and she rubbed her fingers together. *She answered questions with brief responses. *She was lying on her bed, and her legs were in constant movement. Observations on 5/5/25 at 5:27 p.m. and again on 5/6/25 at 7:33 a.m. with resident 19 in the dining room revealed: *She was seated at the table in a dining room chair. *She held tightly to the chair and would scoot forward and back in that chair. *At times, she would stand and then return to sitting. *She appeared restless and anxious. *Her upper body was stiff, and her arms appeared tense. Review of resident 19's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview of Mental Status (BIMS) assessment score of 3, which indicated she was severely cognitively impaired. *Her diagnoses included Wernicke's Encephalopathy, anxiety disorder, amnestic disorder, and drug-induced subacute dyskinesia. *A 3/13/25 physician's order: Complete AIMS assessment in 1 month and fax results. And Nursing to provide fax status update in 1 month on mood/behaviors and PRN [as needed] Lorazepam [medication used for anxiety] use. *AIMS assessments were completed on 11/3/24 and 2/23/24. *There was no documentation that an AIMS assessment had been completed since 2/23/24. *There was no documentation that the physician had been provided the results of the ordered AIMS assessment or had been provided a status update on resident 19's mood/behaviors or Lorazepam use. Interview on 5/8/25 at 8:23 a.m. with director of nursing (DON) C regarding resident 19's 3/13/25 physician's orders revealed: *DON C confirmed that resident 19's last AIMS assessment was completed on 2/23/24. *On 3/24/25, she communicated the results of resident 19's Patient Health Questionnaire-9 (PHQ-9) (an assessment of the degree of depression) to the physician. *She confirmed that they had not conducted the AIMS assessment as ordered on 3/12/25 or provided an update on the use of resident 19's Lorazepam. *She expected that the AIMS assessment would have been completed in mid-April, and the result of that assessment would have been provided to the physician along with an update on resident 19's mood/behaviors and Lorazepam use. Review of the provider's 1/1/25 revised Physician Visit and Physician Delegation policy revealed: *It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. *The Licensed Nurse should: a. Track the due dates of physician visits .e. Provide records such as weight and vital sign records, accident reports, etc. for physician review. *The Director of Nursing or Designee should: a. Conduct monthly audits for timeliness of physician visits. Review of the provider's Physician Medication Orders policy revealed it did not address the following physician orders unrelated to medications. Request for policies related to following physicians' orders resulted in the above-referenced policies. There were no additional polices for review. 2. Interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *He had diabetes. *His blood sugars had been running lower than normal since he admitted to the facility and his physician had been adjusting his insulin doses. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *He had a diagnosis of diabetes. *He had a physician's order to have his blood sugars checked before meals and at bedtime everyday. *He had a physician's order for Novolog Injection Solution 100 units/ ML (Insulin Aspart) [a fast-acting insulin] Inject 25 units subcutaneously [under the skin into the fatty tissue] with meals. Review of resident 25's April 2025 MAR and associated progress notes revealed: *4/10/25 at 5:30 p.m. his insulin was held with a progress note at 7:15 p.m. that stated Resident's BG [blood glucose or blood sugar] was 97 before supper. Resident ate supper. Writer rechecked BG and it was 128. Writer held 30 units and will recheck [blood sugar] at HS [bedtime]. *4/18/25 at 5:30 p.m. his insulin dose was held, his blood sugar was documented as 71 with a progress note at 4:15 p.m. that stated, only 71, holding. *4/19/25 at 11:30 a.m. his insulin dose was held, his blood sugar was 236 with a progress note that stated, Held due to not eating lunch. *4/19/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 88 with a progress note that stated, he is not hungry but will try to eat something. *4/20/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 72. *4/20/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 213 with a progress note that stated, Not eating supper. *4/21/25 at 5:30 p.m. his insulin dose was held with a documented blood sugar of 82, and a progress note that stated, Held due to first blood sugar 60 and after snack it went up to 82. *4/22/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 73. *4/23/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 78. *4/24/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 68. *4/24/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 102. *4/25/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 95. *4/25/25 at 11:30 a.m. his insulin was held with a blood sugar of 119. *4/25/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 144 and a progress note that stated, holding due to not planning to eat much. *4/26/25 at 7:30 a.m. his insulin was held with a blood sugar of 68. *4/26/25 at 5:30 p.m. his insulin was held with a blood sugar of 120. *4/27/25 at 7:30 a.m. his insulin was held with a blood sugar of 84. *4/28/25 at 7:30 a.m. his insulin was held with a blood sugar of 89. *4/30/25 at 5:30 p.m. his insulin was held with a blood sugar of 126 and a progress note that stated, Holding due to a hypoglycemic [low blood sugar] episode at HS recently. *From 4/8/25 until 4/28/25 there was no low blood sugar parameter that would indicate at what blood sugar value the insulin should have been held. *On 4/28/25 at 9:10 a.m. a progress note read, Faxed [medical director N] for parameters to hold his [resident 25's] Novolog 30 units with meals. His blood sugars have been running low, and staff has [have] been holding this at times. Sent recent blood sugars and medication list that he is on for Diabetes. Awaiting response. *On 4/28/25 there was a physician's order that stated, Hold [insulin] if blood sugar is less than 80 added to his insulin order. *Review of resident 25's May 2025 MAR revealed on 5/3/25 at 5:30 p.m. his insulin was documented as held with a blood sugar of 87. Review of resident 25's May 2025 MAR and associated progress notes revealed on 5/3/25 at 5:30 p.m. his insulin was held with a blood sugar of 87 and a progress note that stated, holding due to episodes of hypoglycemia [low blood sugar]. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I related to physician notifications revealed: *She would have notified the resident's physician via fax or a phone call is she held an insulin without a physician's order for a low blood sugar. *She was aware resident 25's insulin had been held related to low blood sugars but did not know if the physician had been notified of the low blood sugars or that his insulin had been held. *She stated if a resident's insulin was held related to a low blood sugar and the resident did not have parameters identified by the physician for when to hold the insulin for a low blood sugar, she was to notify the physician but admitted she had not always notified the physician. -If she notified the physician, she would document that in a progress note in the resident's EMR. *There was no facility identified number of resident refusals of a medication that would indicate the provider was to be notified. *After a few resident medication refusals she would talk with the resident regarding the refusals to determine why the medication was being refused and then would notify the provider. Interview on 5/7/25 at 10:50 a.m. with medical director N revealed: *It was her expectation to be notified immediately if insulin was being held for symptomatic hypoglycemia (low blood sugar) for a resident. *She stated it would be difficult to manage a resident's insulin regimen if the staff were holding insulin and she was not notified. *She was aware resident 25 was having low blood sugars and some adjustments had been made to his insulin regimen. *She recently ordered a low parameter to be added to his scheduled fast acting insulin, which indicated the low blood sugar value in which the staff were to hold his insulin. *He did not have the low blood sugar parameter for holding his insulin at the time of his admission. Documentation of the physician having been notified of the held insulin doses was requested from the facility but was not provided by the end of the survey on 5/8/25. Interview on 5/7/25 at 2:15 p.m. with director of nursing (DON) C revealed: *The facility did not have a policy regarding physician notification related to held or refused medications. *It was her expectation the physician was notified if medications were held without a physician's order. 3. Review of the provider's April 2013 Diabetes-Clinical Protocol policy revealed: *The staff will identify and report complications such as foot infections, skin ulcerations, increased thirst, or hypoglycemia. *The physician will help the staff clarify and respond to these episodes. Review of the provider's 3/5/25 Blood Pressure and Blood Sugar Parameter Policy revealed: *If blood sugar levels are above 400 or below 70 alert the provider. Unless other parameters are noted on residents' chart by their physician. *Chart communication with family and provider. Review of the provider's October 2021 Notification of Resident Changes policy revealed: *It is the policy of the facility that a resident's change in physical, medical, or psychological condition or treatment is promptly communicated to the resident, the designated resident's representative (if applicable) and the Primary Care Provider. *The charge nurse on duty at the time of the event will be responsible for immediate notification to the resident, resident representative(s) and the PCP [primary care provider] regarding the following: -c. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

Based on observation, interview, record review, and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate counts and complete documentation of those medications in one of one medication cart and one of one refrigerators that contained controlled medications. Findings include: 1. Observation and interview with licensed practical nurse (LPN) F on 5/6/25 at 9:40 a.m. of a binder labeled Narcotic Binder on the east medication cart revealed: *A form in the front of the binder was labeled Control E-Kit [emergency kit for controlled medications] Shift Count. *The area for the month and year o that form was blank. -LPN F verified that form was for May 2025. *That Control E-Kit Shift Count form had six medications identified on it: -Tramadol [ a pain medication] 50 mg [milligrams] PO [by mouth]. -Oxycodone [a pain medication] 2.5 mg tab PO. -Morphine [a pain medication] 10 mg/0.5 ml [milliliters] PO/SL [sublingual] . -Hydrocodone/APAP [a pain medication] 5/325 mg PO. -Lorazepam[an antianxiety medication] 0.5 mg PO . -Lorazepam 2 mg/ml IM/IV [intermuscular/intravenous]. *That Control E-Kit Shift Count form had locations to document for each day of the month for both day and night counts that included: -The number of pills or syringes counted. -The initials of the persons that counted those medications with an indicator that there was to be two persons. *The Controlled E-Kit Shift Count form documentation indicated: -On 5/1/25 there was no second staff's initials for the day count and no count or initials for the night count. -On 5/2/25 no documentation was completed. -On 5/3/25 there was no count or initials for the day count, and no second staff's initials for the night count. -5/5/25 there was one missing initial for the night count. *Another form labeled Narcotic E-Kit Numbers was in the narcotic binder. -That form had areas for each day to document two staff's signatures for the First Shift and Second Shift and a number on the E-Kit lock tags for the Gray Cupboard E-Kit, the East Narc [narcotic] Drawer E-Kit, and the Fridge E-Kit. -On 5/2/25 there were no numbers documented in the three columns and the second shift only had one signature documented. 2. Interview on 5/6/25 at 9:50 a.m. with LPN F revealed: *The Controlled E-Kit shift count form was how the staff documented the counts emergency supply of controlled medications. *The controlled medications were to be counted at the change of shift by the oncoming and outgoing staff to verify the medications counts were accurate. *Each one of the three different emergency medication kits were sealed with a numbered tag. *The Narcotic E-Kit Form was where the tag numbers on each kit were documented to be sure no had broken the tag and accessed the kit without prior authorization from the pharmacy to remove a medication for administration to a resident. *The numbers on the identified tags were to be checked and documented at change of shift by two staff members on the Narcotic E-Kit Numbers form. *LPN F verified there was incomplete documentation on both forms for May 2025. *LPN F stated the controlled substances prescribed to individual resident were sent from pharmacy in a bubble pack medication card system and stored in a locked drawer in each medication cart. *The individual residents'controlled medications were counted at each change of shift but there was no form to document that count had occurred for those medications. 3. Interview on 5/6/25 at 10:22 a.m. with LPN I revealed: *The controlled medication counts were to be completed on the E-Kits and for each resident that was prescribed a controlled medication at the change of each shift by two nursing staff members authorized to administer medications. *The E-Kit controlled substances were stored in the east medication cart within the locked drawer and in a locked compartment in the refrigerator. *The signatures on the forms were to indicate that the controlled medication counts were completed and accurate and the tags were checked and found to be in place and the tag numbers were accurate. *There was no location to document the individual residents' controlled medications counts had been completed or who completed those counts to verify the accuracy of the amount of those medications present. 4. Review of April 2025 Control E-Kit Shift Count form revealed: *The day counts did not have documentation of the second staff member's initials ten times. *The night counts did not have documentation of the second staff member's initials nine times. Review of March 2025 Control E-Kit Shift Count form revealed: *The day count was missing documentation of the count on 3/17/25 and did not have documentation of the second staff member's initials nine times. *The night counts did not have documentation of the second staff member's initials seven times. Review of February 2025 Control E-Kit Shift Count revealed: *The day count was missing documentation of the count two times and did not have documentation of the second staff member's initials seven times. *The night count was missing documentation of the count two times and did not have documentation of the second staff member's initials five times. Review of January 2025 Control E-Kit Shift Count revealed: *The day count was missing documentation of the count five times and did not have documentation of the second staff member's initials eleven times. *The night count was missing documentation of the count three times and did not have documentation of the second staff member's initials thirteen times. Review of December 2024 Control E-Kit Shift Count revealed: *The day count was missing documentation of the count seven times and did not have documentation of the second staff member's initials nine times. *The night count was missing documentation of the count five times and did not have documentation of the second staff member's initials twelve times. 5. Review of April 2025 Narcotic E-Kit Numbers revealed: *On 4/3/25 no tag numbers were documented, and one signature was documented for the first shift and the second shift. *On 4/29/25 no tag numbers were documented. *Only one signature was documented for either the first or the second shift seven. 6. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *It was her expectation that all controlled medications were to be counted by two licensed staff members or certified medication aides (CMA) at every change of shift. *The counts were to be documented on the Control E-Kit Shift Count in the front of the narcotic binder. *The signatures on the document would indicate the controlled medication counts had been completed and the counts were accurate. *The tag numbers were to be verified and documented as accurate by two staff members, and she expected that to have been completed at the same time the controlled medications were counted. *She was aware there was no location to document the counts were completed and by which staff members for the residents' controlled medications. -She did not feel that there needed to be a form to document that. The staff were to complete the counts at the change of shifts and were to notify her if there was a discrepancy. *She verified without the documentation of the counts of the residents' controlled medications she would not be able to determine who or when the last count had been completed. *She was not aware of the frequency of missing or incomplete documentation on the Control E-Kit Shift Count forms or the Narcotic E-Kit tag numbers. 7. Review of the provider's 11/5/15 Storage of Facility E-Kit Documentation policy revealed Emergency controlled substances [medications] must be stored in a double lock system and verified shift to shift. Review of the provider's 12/1/15 Emergency Kits policy revealed A Control E-Kit Shift Count will be used by facility staff to keep track and use for counting controlled case medications shift to shift on a monthly basis. Review of the provider's undated Narcotic Count policy revealed: *Narcotics [controlled medications] will be counted by licensed nursing personnel to assure they are properly accounted for at the beginning and ending of each shift. *The on-going and off-going nurse at shift change will perform a physical count of the narcotic drawer. *Each nurse will sign the narcotic count sheet when the count is completed. Review of the provider's November 2017 Controlled Medication Storage policy revealed: *At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. *Current controlled medication accountability records are kept in the MAR [medication administration record] or narcotic book.

Based on observation, interview, record review, and policy review the provider failed to ensure: *Medications with shortened expiration dates [medications that, after opening, expire prior to the manufacturer's expiration date] were labeled properly and disposed of after having outdated for three sampled residents (3, 14, and 79) and one random resident (24) in two of two medication carts and one of one treatment cart. *Daily temperatures of one of one refrigerator containing medications were monitored and document according to the provider's policy for twelve of twelve months reviewed in 2024 and two of two months (March and April) in 2025. *Daily temperatures of one of one area used to store medications was monitored and documented according to the provider's policy. *Medication labels matched the current physician orders for four of four sampled residents (15, 19, 22, 25) according to the provider's policy. Findings include: 1. Observation and interview on 5/6/25 at 7:30 a.m. with licensed practical nurse (LPN) during medication pass revealed: *Resident 19's gabapentin (medication for seizures or nerve pain) pharmacy medication label read 400 mg (milligrams) give 1 cap three times daily and her order on the medication administration record (MAR) read gabapentin 100mg, give 400 mg three times daily. *Resident 15's midodrine (medication for low blood pressure) pharmacy medication label read give 10 mg three times per day and her MAR stated 5 mg give two tabs daily with meals. *Resident 15's duloxetine (medication for depression) pharmacy medication label read give 60 mg give one cap daily and her MAR stated 30 mg, give 2 caps in the morning. 2. Observation and interview on 5/6/25 at 9:50 a.m. of the medication carts with LPN F revealed: *Resident 22's Lantus (long-acting insulin) insulin label with the directions for administration was covered by the opened and expired label and was not readable. *Resident 79's Trelegy Ellipta inhaler (medication to treat breathing problems) was opened. -The box had a sticker that had a location to document the medications opened date and expirations date, but neither the opened date nor the expired date were written on the sticker. *Resident 3's Trelegy Ellipta inhaler was opened. -The box had a sticker that had a location to document the medications opened date and expirations date, but neither the opened date nor the expired date were written on the sticker. *Resident 79's Ventolin HFA (fast acting medication for breathing problems) inhaler was opened and was not marked with the date it was opened. *Resident 24's Latanoprost (medication used to treat increased pressure in the eye) eye drops were marked as opened on 3/21/25 and had an expiration date identified as 5/2/25. *Resident 14's Latanoprost eye drops were opened and dated on 3/20/25 with an expiration date of 5/1/25. *LPN F was not aware there were medications with shortened expiration dates after they were opened or removed from the refrigerator other than insulin. *She verified the Latanoprost eye drops for residents 14 and 24 were outdated and remained in the medication cart for potential use. *There was a reference in the drawer of the medication cart that was identified as MEDICATIONS WITH SHORTENED EXPIRATION DATES. 3. Review of the undated Medication with Shortened Expiration Dates reference revealed: *Ventolin HFA inhalers were to be discarded 12 months after the removal from its protective pouch. *Latanoprost eye drops were to be discarded six weeks after opening. *Trelegy Ellipta inhalers were to be discarded six weeks after opening the foil tray. 4. Observation, interview, and record review on 5/6/25 at 10:21 a.m. in the room located behind the nurses' station with LPN I revealed: *LPN I identified the black locked refrigerator in the room as the refrigerator that was used to store residents' medications. *She stated the temperature inside the refrigerator was measured and documented daily by the night nurse. -She verified there were dates with missing medication refrigerator temperatures for 2024 and 2025 on the documentation sheets. *She was aware there were medications with shortened expiration dates after opening and was aware of the reference in the medication cart to help identify those medications. 5. Review of the documentation of the medication refrigerator temperatures for 2024 revealed: *January had three days without a documented temperature. *February had five days without a documented temperature. *March had six days without a documented temperature. *April had nine days without a documented temperature. *May had five days without a documented temperature. *June had seven days without a documented temperature. *July had six days without a documented temperature. *August had one day without a documented temperature. *September had six days without a documented temperature. *October had one day without a documented temperature. *November had five days without a documented temperature. *December had six days without a documented temperature. Review of the documentation of the medication refrigerator temperature for 2025 revealed: *March had one day without a documented temperature. *April had six days of documented temperatures that were out of the acceptable temperature range of 36 to 46 degrees Fahrenheit. -Five of those days the temperature of the medication refrigerator was 34 degrees Fahrenheit. -One day the temperature of the medication refrigerator was 32 degrees Fahrenheit. 6. Observation and interview on 5/6/25 at 2:33 p.m. of the treatment cart with LPN I revealed: *She would be unable to determine what the expiration date of a medication with a shortened expiration date was without the date documented that the medication was opened. *There was a container of Silver Sulfadiazine cream that was labeled as stock supply and dated as opened on 2/4/24. *Resident 25's Tresiba (long-acting insulin) injectable pen's pharmacy label indicated he was to receive 100 units daily and his MAR indicated he was to receive 90 units daily. -There was no label or indication on the Tresiba pen that the dose of the medication had been changed. *She was aware there were labels on oral medications and insulins that did not match the orders in the MAR and there was no indication the order had been changed on those medications' labels. *She stated that pharmacy did not replace the labels on medications when the orders changed. *The facility utilized certified medication aides to administer medications. *She agreed she could not complete her checks for the correct medication doses when the labels and the MAR did not match but she would administer medications according to the instructions in the MAR. 7. Interview on 5/7/25 at 2:15 p.m. with director of nursing (DON) C revealed: *The did not have a room identified as a medication room. *Medications were stored in the locked cabinets and refrigerator located behind the nurses' station desk if they were not stored in the medication cart. *She stated the facility did not have a policy or documentation log for room temperatures where medications were stored. Interview on 5/8/25 at 11:30 a.m. with DON C revealed: *She was aware there were medications with shortened expiration dates after being opened or removed from refrigeration. *It was her expectation that all medications were dated with the date they were opened. *If there was an ordered medication dose change staff was supposed to apply a label on the medication container that indicated there had been a dose change. *She agreed the MAR and the pharmacy label not matching increased the risk for a medication error especially with the use of CMAs that may not be able to identify medications and could not calculate dosages. *After review of the documentation for the medication refrigerator temperatures she verified there was missing documentation of temperatures and there were temperatures in April that were outside of the acceptable range. *She was not aware there was documentation and temperatures outside of the acceptable range. *The temperature of the area where the medications were stored was not being monitored and documented. *She agreed the temperature of the room could not be verified as within an acceptable range if the temperature was not monitored and documented. 8. Review of the provider's 6/1/24 Medication: General Rules policy revealed: *Only pharmacy can replace labels on medications. For order changes involving time changes or frequency changes, 'order change, see chart' labels may be used until the pharmacy replaces the label on medication. *Medications will be given adhering to the 'Six Rights'. Right DRUG, Right RESIDENT, Right ROUTE, Right DOSE, Right MED FORM and Right TIME. *The person administering the medication will also be responsible for Checking expiration dates. Review of the provider's 2/1/25 Medication Storage in the Facility policy revealed: *Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are [to be] immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. *All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Center for Disease Control (CDC). -1) Room Temperature 59 [degrees] F [Fahrenheit] to 77 [degrees] F (15 [degrees] C [Celsius] to 25 [degrees] C. -2) Controlled Room Temperature (the temperature maintained thermostatically) 68 [degrees] F to 77 [degrees] F (20 [degrees] C to 25 [degrees] C). -3) Refrigerated 36 [degrees] F to 46 [degrees] F (2 [degrees] C to 8 [degrees] C) with a thermometer to allow temperature monitoring. *The Facility should maintain a temperature log in the storage area to record temperatures at least once a day. *Medications in multi-dose packaging will have a beyond-use dating of 60 days or manufacturer's expiration date if less than 60 days. *The nurse will check the expiration date of each medication before administering it. *No expired medication will be administered to a resident. *All expired medications will be removed from the active supply and destroyed in the facility, regardless of [the] amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure enhanced barrier precautions (EBP) were followed according to the provider's policy for two of two sampled residents (25 and 79) on EBP. Findings include: 1. Observation and interview on 5/6/25 at 9:08 a.m. with resident 79 in her room revealed: *A sign on her door stated she was on EBP and included the following: -Everyone must clean their hands, including before entering and when leaving the room. -Providers and staff must also wear gloves and a gown for the following high-contact activities: --Dressing. --Bathing/showering. --Transferring. --Changing linens. --Providing Hygiene. --Changing briefs or assisting with toileting. *Device care use: -Central line, urinary catheter, feeding tube, tracheostomy. -Wound care: any skin opening requiring a dressing. *There was no personal protective equipment (PPE) (gowns, gloves, and/or protective eyewear) available for use on or near the door. *She was not sure why the sign was on her door. Review of resident 79's EMR regarding EBP revealed: *She was readmitted on [DATE] following a hospital stay for a procedure. *She had an incision with staples from that procedure, with a physician's order to keep the area clean and dry. *There was nothing identified in her EMR that indicated the need for EBP. 2. Interview on 5/7/25 with certified nursing assistant (CNA) L at 2:15 p.m. regarding the EBP sign on resident 79's door revealed: *Resident 79 had returned from the hospital on Monday (5/5/25). *She was unsure why the EBP sign was on the resident's door. *Staff were to wear a gown and gloves when providing her care if she was on EBP. *Gowns were kept in the bottom drawer of the resident's dresser. *The nurse would inform the staff if there were any changes in infection control for residents so they would know what PPE to wear when caring for the residents. 3. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *There was a sign on the outside of his door to his room that indicated he was on EBP. *There was no PPE available for use on his room door or near the room's entrance. *He stated he was at the facility to receive therapy services and planned to return home after his therapy was completed. *He indicated he had a surgical wound on his right lower leg that required a daily dressing change. *He stated the staff wore gloves when they changed his dressing and assisted him with cares, but they did not wear a gown. *He was not aware of any gowns being stored in or near the entrance to his room. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. *There was a physician's order that indicated, Right ankle apply Silvadene [a topical antimicrobial cream] and change dressing daily. one time a day for surgical site. related to DISPLACED FRACTURE OF LATERAL MALLEOLUS OF RIGHT FIBULA [right ankle fracture]. Review of resident 25's care plan revealed: *An intervention for Enhanced Barrier Precautions (EBP) to be used when providing cares for [resident 25]. EBP includes ABHR [alcohol-based hand rub] to hands before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities: when caring for [resident 25's] left ankle wound, assisting him with dressing, undressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. *Resident 25's care plan indicated he required assistance from one staff for showering, dressing, toileting, and transferring. 4. Interview on 5/6/25 at 4:47 p.m. with certified nursing assistant (CNA) Q revealed: *Residents were on EBP if they had catheters or wounds. *She usually only wore gloves when providing resident cares for residents on EBP. *She indicated she had previously worn gowns but was no longer was required to because the wounds (in relation to all residents on EBP for wounds) were covered. 5. Observation on 5/7/25 at 8:28 a.m. of resident 25 in the therapy area revealed: *No staff in the therapy area were wearing a gown or gloves. *Physical therapy assistant (PTA) P placed a gait belt on resident 25, assisted him to a standing position, and walked with him with a walker, and providing continuous contact assistance without wearing any PPE. 6. Interview on 5/7/25 at 9:36 a.m. with PTA P revealed: *She had been provided education related to EBP. *She was aware of which residents required EBP by the sign that was posted on the resident's room door. *She thought she only needed to wear PPE for EBP is she was in the resident's room and had not worn PPE in the therapy area while she provided therapy services for the resident. 7. Interview on 5/7/25 at 10:02 a.m. with licensed practical nurse (LPN) I revealed: *Residents with catheters, wounds, and certain infections required EBP. *The gowns were stored in the closets in the resident rooms. *She would put on a gown as soon as she entered the room to provide cares for residents on EBP. 8. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *She was the infection preventionist (IP) for the facility. *A gown and gloves were to be worn when providing direct resident care for residents with wounds, catheters, and the residents who had multidrug-resistant organisms (MDRO), which would require the resident to be on EBP. *The same PPE required for in-room care for residents on EBP was to be worn in the therapy area for those residents. *She had not thought of providing a PPE supply to be available for use in the therapy area. *It was her expectation that all facility staff and therapy staff followed the requirements for EBP. 9. Review of the provider's February 2025 Enhanced Barrier Precaution Policy revealed: *EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -High-contact resident activities include: --Dressing --Bathing/Showering --Transferring --Providing Hygiene --Changing linens --Changing briefs or assisting with toileting --Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator --Wound care: any skin opening requiring a dressing *Enhanced Barrier Precautions should be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

Based on interview, policy review, and record review, the provider failed to implement an effective antibiotic stewardship program according to their policy related to: *Ensuring residents' symptoms were present and documented prior to contacting their physicians related to potential infection. *Reviewing infections and antibiotics for possible trends. *Completing and annual summary of antibiotic use in the facility and reporting that to the QAPI committee. *Having an antibiogram (a table that shows which antibiotics are most likely to be effective against specific bacteria) done every 18-24 months to guide development or revision of antibiotic use protocols. *Following up annually with physicians regarding antibiotic use for residents. Findings include: 1. Interview on 5/8/25 at 9:34 a.m. with director of nursing (DON) C regarding the facilities antibiotic stewardship program and policy revealed: *She was the infection preventionist for the facility and was in charge of the antibiotic stewardship program. *The facility used a situation-background-assessment-recommendation (SBAR) form that was based off McGeer criteria for infection surveillance and monitoring. *The SBAR form was used for suspected respiratory, urinary, and soft tissue infections of the residents. *DON C stated the facility was not 100% compliant with the use of the SBAR form when a resident had symptoms of urinary tract infections because she felt they [the staff] know when a resident had a change in their health status. *When asked what not 100% compliant meant she stated the facility was noncompliant almost always. *She stated if the staff waited for all the symptoms required with the criteria on the SBAR form to obtain a urinalysis (UA) order from the physician then the resident would have been more ill than if the urinary tract infection (UTI) was identified earlier. *DON C stated she had discussed this with medical director N and at times medical director N would refuse the order request for a UA by stating the resident required more symptoms for a UA to be ordered. *DON C was responsible for ensuring the facility received all lab and other diagnostic testing results that had been ordered at the facility and following up with the resident primary physician regarding the results. *She tracked the facility's use of antibiotic by printing out a report that was provided by the facility's contracted pharmacy that listed the antibiotics used by residents for the dates selected when the report was run. -That report included the resident name, the name of the antibiotic or antifungal medication with the instructions for use, when the medication was dispensed, when the medication was started, and the number of days the medication was administered. -That report did not include the diagnosis or indication for use of the medication, if the antibiotic was determined appropriate or necessary upon the receipt of the results of the diagnostic testing had been received. *She did not monitor infections related to the resident's location within the facility to identify potential clusters of residents with infections. *The only tracking she completed related to illness and antibiotic use was reviewing the monthly antibiotic use that was documented in the report provided by the facilities contracted pharmacy during the monthly Quality Assurance and Performance Improvement (QAPI) meeting after she removed the antibiotics that were taken by residents for the prevention of infections from the report. Continued interview and review of the provider's 3/22/18 Antibiotic Stewardship Program policy with DON C revealed: *She had not been following the policy in the following areas: -She talked about the antibiotic use monthly but did not complete an annual summary. -There were no antibiotic stewardship meetings held as the facility policy indicated. -She did not complete random audits for resident's antibiotic use. -She did not track one outcome measure associated with antibiotic use monthly. -The facility did not have an antibiogram to review. -She did not follow up with the prescribing physicians annually regarding their use of antibiotics for the residents. Continued interview on 5/8/25 at 11:30 a.m. with DON C revealed she was not aware that the facilities infection rate for UTIs for long-stay residents was above the state and national average according to the facilities reported quality measures. 2. Review of the providers 3/22/18 Antibiotic Stewardship Program policy revealed: *It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. *The program includes antibiotic use protocols and a system to monitor antibiotic use. -a. Antibiotic use protocols: --i. Nursing stall shall assess residents who are suspected to have an infection and complete a Medical Care Referral Form prior to notifying the physician. --ii. Laboratory testing shall be in accordance with current standards of practice. --iii. The facility uses the (CDC's [Center for Disease Control] NHSN [National Healthcare Safety Network] Surveillance Definitions) to define infections. --iv. The Loeb Minimum Criteria are used to determine whether or not to treat an infection with antibiotics. *Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). *At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include: tracking C. difficile infections, antibiotic resistance, or adverse drug events related to antibiotic use. *At least annually, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, and the QAA [quality assessment and assurance] Committee. *A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices. *At least annually, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report. *Documentation related to the program maintained by the Infection Preventionist, including but not limited to: -a. Action plans and/or work plans associated with the program. -b. Assessment forms. -c. Antibiotic use protocols/algorithms. -d. Data collection forms for antibiotic use, process, and outcome measures. -e. Antibiotic stewardship meeting minutes. -f. Feedback reports. -g. Records related to education of staff, residents, and families. -h. Annual reports. Review of the provider's 10/12/17 Infection Reporting policy revealed The Infection Preventionist will report findings of surveillance activities, including at a minimum incident rates and types of infections, to the QAA committee, physicians, and other appropriate staff. 3. Review of the provider's March 2025 Facility Assessment revealed: *We track and trend infections. *We have monthly infection control meetings and quarterly QAPI meetings with our medical director, consulting pharmacist and Leadership team to discuss any issues. *We have developed an Antibiotic Stewardship Policy and Procedure and have educated our staff, medical providers, pharmacy consultant, residents and their families.

Based on interview, and record review, the provider failed to ensure that one of one designated infection preventionist (director of nursing C) had completed specialized training in infection prevention and control. Findings include: 1. Interview on 5/8/25 at 9:34 a.m. with director of nursing (DON) C revealed: *She was the designated infection preventionist for the facility. *She was haired on 10/7/21. *She had started the Center for Disease Control's (CDC) specialized infection prevention and control training, Nursing Home Infection Preventionist Training course, in October 2022. *She did not have a certification of completion for the Nursing Home infection Preventionist Training Course. *She was not aware that she had not completed the entire course. Record review of DON C's certificates of completion of modules of the CDC's Nursing Home Infection Preventionist Training Course revealed: *Module 1- Infection Prevention and Control Program with a completion date of 10/5/22. *Module 2- The Infection Preventionist with a completion date of 10/5/22. *Module 3- Integrating Infection Prevention and Control into the Quality Assurance Performance Improvement Program with a completion date of 10/5/22. *Module 4- Infection Surveillance with a completion date of 10/5/22. *Module 5- Outbreaks with a completion date of 10/5/22. *DON C had not completed 18 of the 23 modules required for completion of that course.

Based on interview, observation, record review, policy review, and job description review the provider failed to ensure the facility was operated under the supervision of administrator A to ensure quality management and the overall well-being of all 26 residents in the facility. Findings include: 1. Interview on 5/6/25 at 4:35 p.m. with administrator A regarding his schedule revealed: *He tried to be in the building weekly. *If he was unavailable, administrator B would be in the building once a week. *Administrator B started coming to the building once a week in January 2025. *Director of nursing (DON) C, business manager (BM) O, and dietary manger E were to be in the building on a full-time basis. 2. Interview on 5/7/25 at 9:59 a.m. with administrator B regarding department managers' time in the building revealed: *She did not know administrator A's schedule. *She was the full-time administrator for another facility. *If administrator A was unavailable, she would be in the building one day a week. *She started coming to the building on a weekly basis in January 2025 to help implement a new quality improvement plan. *The maintenance supervisor worked 10 hours a week and was on-call. *The minimum data set (MDS) coordinator worked in the facility on Mondays and Tuesdays and would work remotely after that. 3. Interview on 5/8/25 at 9:04 a.m. with licensed practical nurse (LPN)/social services designee (SSD) D regarding her schedule revealed: *She normally worked on Mondays and Thursdays as the SSD. *She would also fill in as a charge nurse when needed. *If a new resident admission was scheduled for a different day, she worked it out with DON C to cover the admission process. 4. Interview on 5/8/25 at 10:23 a.m. with administrator A regarding the day-to-day operations of the facility revealed: *He was the administrator of record for the facility. *DON C and BM O addressed most of the day-to-day activities in the building. *If there was an issue they could not address, they contacted administrator A or administrator B. *Administrator A or administrator B would come to the building and address the situation that day. *He agreed there were a lot of management issues delegated to DON C and BM O to ensure resident services were being provided and the regulation requirements were being met. 5. Interview on 5/8/25 at 11:44 a.m. with DON C regarding administrative oversight revealed: *Most of the facility's administrative duties fell upon her and BM O. *She stated she struggled to do her job as the DON while covering for other departments, including administration. *She would address issues in other departments, which took time away from completion of her director of nursing responsibilities. *If she had a major issue, she would call or email administrator A. *Administrator A's response time was not always timely. *Her responsibility of over-seeing the quality assurance meetings were turned over to administrator B as of 5/5/25 to lighten her work load. BM O was out of the office during the survey and unavailable for an interview. Review of the provider's undated Administrator job description revealed: *The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents. *As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. *Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. *Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities. *Ensure that all employees, residents, visitors, and the general public follow established policies and procedures. *Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility. *Assist the Infection Control Coordinator, and/or Committee, in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks involving potential exposure to blood/body fluids are properly identified and recorded. *Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Refer to F554, F655, F657, F658, F695, F699, F755, F761, F812, F865, F868, F880, F881, and F882.

Based on interview and policy review, the provider failed to ensure they had an effective quality assurance and performance improvement (QAPI) program that identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding medication administration and storage, care plans, the completion of assessments, oxygen equipment use, trauma informed care, safe food storage, and infection control. Findings include: 1. Interview on 5/8/25 at 11:22 a.m. with director of nursing (DON) C regarding quality assessment and assurance (QAA) and QAPI revealed: *She was responsible for overseeing the facility's quality management program, including QAA committee meetings and QAPI projects. *Each department manager conducted their own audits, discussed those audits with the QAPI committee, and implemented any plan needed for correction. *The QAPI committee was currently looking at areas that included restraints, skin infections, and ensuring call lights were within reach. *The QAPI committee's current PIP was focused on improving communication with the medical provider regarding laboratory results. *She was unaware of areas of non-compliance regarding : -Medication administration and storage concerns related to resident self-administration of medications, accountability, storage, labeling, and notification to the provider when medications were withheld. -Baseline Care Plan concerns related to providing those to the resident/representative within 48 hours of admission. -Care Plan revisions accurately reflected the current care needs of the residents. -Ensuring that assessments were completed as ordered by the physician, and weekly skin assessments were completed by a licensed nurse. -Proper cleaning, storage, and supervision of oxygen equipment, -Trauma-informed care assessments were completed on residents who were identified as having Post Traumatic Stress Disorder (PTSD) -Safe food storage in the kitchen. -Infection Prevention and Control related to the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP), antibiotic stewardship, and training requirements of the infection preventionist. *She stated the QAPI committee was not aware of the issues above. *She confirmed their QAPI process had not been effective in identifying those quality issues that could have impacted the residents' care. *She had requested that another QAA member be assigned the responsibility for overseeing the QAPI program. Review of the providers' reviewed 12/1/23 QAPI plan policy revealed: *The QAPI program will aim for safety and high quality with all clinical interventions and service delivery . by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. *The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions . *The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program and for: 1) Identifying and prioritizing problems based on performance indicator data . 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness . Refer to F554, F655, F657, F658, F695, F699, F755, F761, F812, F835, F868, F880, F881, and F882.

Based on interview, record review, and policy review, the provider failed to ensure the quality assessment and assurance (QAA) committee had included the required members of at least one of who was the administrator, owner, a board member, or other individual in a leadership role. The provider had no evidence of the administrator, owner, board member, or other designee having attended QAA meetings at least quarterly for 15 months of meeting attendance records reviewed (February 2024 through May 2025). Findings include: 1. Interview on 5/7/25 at 10:49 a.m. with medical director (MD) N regarding the provider's QAA and Quality Assessment and Performance Improvement (QAPI) meetings and program revealed: *She attended QAPI meetings quarterly and did not recall seeing administrator A present at those meetings routinely. *She was unaware of how often administrator A was at the facility or how often he attended the QAPI meetings in the past two years. *She expected that the administrator would be involved in identifying and correcting areas of concern identified in the QAPI program. -She indicated the facility could use his support. 2. Interview on 5/8/25 at 11:22 a.m. with director of nursing (DON) C regarding QAA and QAPI revealed: *She was responsible for overseeing the facility's quality management program, including QAA committee meetings and QAPI projects. *The QAA committee was expected to meet monthly. *The provider's QAPI committee was comprised of department managers and DON C. *The medical director and the consultant pharmacist attended QAPI meetings quarterly. *Administrator A attended the QAPI meeting that week for the first time in quite a while. *Administrator B had been at the facility approximately three hours a week for the last couple of months, but she had not attended a QAPI meeting. *She had requested that another QAA member be assigned the responsibility for overseeing the QAPI program. 3. Review of the provider's previous 15 months of monthly QAPI Meeting Attendance records revealed: *Between 2/13/24 and 5/6/25, administrator A attended two QAPI meetings. -He attended on 6/25/24 and 5/6/25. *None of the meetings were attended by the owner, a board member, or another individual in a leadership role. Review of the providers' reviewed 12/1/23 QAPI plan policy revealed: *Governance and Leadership: -The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program and for: 1) Identifying and prioritizing problems based on performance indicator data. 2) Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4) Setting clear expectations for safety, quality, rights, choice, and respect. 5) Ensuring adequate resources exist to conduct QAPI efforts. *The QAPI program will be structured to incorporate input, participation, and responsibility at all levels. The Governing Body and QAPI Committee of the nursing center will develop a culture that involves leadership-seeking input from nursing center staff, residents, their families, and other stakeholders; encourages and requires staff participation in QAPI initiatives when necessary; and hold staff accountable for taking ownership and responsibility of assigned QAPI activities and duties. *QAPI Committee Members were listed as: Medical Director, Director of Nursing, Administrator, Infection Control Officer, Environmental Manager, Activities Director, Social Services Designee, Dietary Manager, and Business Manager. Refer to F835 and F865.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure the proper Medicare notices were completed and provided for one of three sampled residents (2) prior to discharge from skilled services. Findings include: 1. Review of resident 2's CMS (Centers for Medicare and Medicaid Services) SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by social service designee F on 1/4/23 revealed the Medicare Part A Skilled Services Episode start date was 5/18/23 and the last covered date was on 7/2/23. Review of resident 2's electronic medical record revealed: *He was admitted on [DATE]. *He was re-admitted on [DATE]. *He had skilled covered days remaining and continued to reside in the facility. *His Notice of Medicare Non-coverage (NOMNC) was signed on 7/20/23 with the benefit's expiring on 7/3/23. *His SNF Advanced Beneficiary Notice of Non-coverage form was signed on 7/20/23. -That standardized notice would allow Medicare beneficiaries to make informed decisions about whether to receive certain Medicare services and accept financial responsibility for those services if Medicare would not cover the cost of those services. *Both forms were completed seventeen days after his last covered day of Part A services had ended. Interview on 1/4/24 at 12:00 p.m. with social service designee F revealed she: *Was a licensed practical nurse who worked as the social service designee. *Was responsible for issuing the Medicare notices. *Relied on e-mails from the director of rehabilitation (DOR) which informed her of when a resident's skilled services were ending. *Was not sure why resident 2's Medicare notices were not signed in a timely manner and could not find an e-mail from the DOR informing her of resident 2's end of skilled therapy services. *She recalled discussing the Medicare notices with resident 2's son/durable power of attorney for health care, but stated that the phone conversation was on 7/17/23 and she had mailed the forms to him for his signature. *She agreed that resident 2's representative was not given a two-day notice before the end of his skilled services. Interview on 1/4/24 at 12:53 p.m. with director of nursing (DON) B revealed she: *Confirmed the process for reviewing residents' Medicare Part A stays with therapy services informing both social service designee F and herself of a resident's discharge from skilled services through an e-mail from the DOR. *Stated she could not find an e-mail communication from the DOR regarding resident 2's end of skilled therapy services. *Agreed the Medicare notices above were not provided timely. *Stated the reason why resident 2's Medicare notices were late was due to the miscommunication between therapy services and the provider. Review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 provided to social services designee F revealed: *When to Deliver the NOMNC. -The NOMNC must be delivered at least two calendar days before Medicare-covered services end .

Based on observation, record review, and interview the provider failed to ensure an individualized care plan for one of one sampled resident (23) who had a pressure ulcer had been developed, reflecting identified interventions and implementation and evaluation of them. Findings include: 1. Observation on 1/3/24 at 9:26 a.m. of resident's heel lift boot sitting on his dresser, and no pillow under left foot while the resident was lying in bed on his right side with his heels laying on the bed. 2. Review of resident 23's electronic medical record (EMR) revealed: -On 5/10/23 a physician's order was received to cleanse the stage three pressure ulcer (the wound has burrowed through the second layer and has reached the subcutaneous tissues [fat layers]) with wound cleanser and gauze, apply Medi honey gel, and apply a bordered foam dressing. Change twice daily. -Elevate his left heel on a pillow or use the heel lift boot while he was in bed. Review of resident 23's care plan: -On 10/30/23 his care plan was revised but did not indicate the left heel pressure ulcer or interventions to elevate his left heel on a pillow or use the heel lift boot while in bed. *On 1/2/24 the care plan was revised but did not indicate the left heel pressure ulcer or interventions to elevate his left heel on a pillow or use the heel lift boot while the resident was lying in bed. 3. Interview on 1/4/24 2:55 p.m. with director of nursing (DON) B regarding resident 23's heel lift boot revealed: *She had agreed that interventions should have been on care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Observation and interview on 1/3/23 at 8:25 a.m. with resident 17 revealed: *His bed had two quarter bed rails in the raised position. *He had used the bed rails for repositioning in bed and to assist him in sitting up. Review of resident 17's EMR revealed: *On 11/22/22 a physician ordered May have bilateral quarter bed rails for body positioning/transferring/bed mobility. *His 10/23/23 Bed Rail/Assist Bar Evaluation stated that the resident used the bilateral half bed rails for bed mobility, repositioning, and getting in and out of bed. The bed rails assisted him to maintain his mobility. The MDS for resident 17 was signed on 10/23/23 at 2:00 p.m. and coded as a restraint for daily use by MDS coordinator D. 11. Observation and interview on 1/3/23 at 9:38 a.m. with resident 23 revealed: *He was lying in bed with two half bed rails in the raised position. *He stated that he used the bed rails for repositioning, moving in bed, and to assist him in sitting up. Review of resident 23's EMR revealed: *On 10/9/23 a physician order that indicated may use bilateral top bed rails for bed mobility, body positioning, and assistance getting in and out of bed. *Bed rail assessments dated 10/2/23 stated the resident used the half rails for bed mobility, body positioning and assistance getting in and out of bed. *Bed rail assessment dated [DATE] stated the resident used bilateral top quarter rails to aid in bed mobility, repositioning and assistance getting in and out of bed. The signed MDS for resident 23 dated on 12/26/23 at 3:46 p.m. was coded for restraint use daily. Review of the provider's 7/14/21 Bed Rails policy revealed: *The Purpose: -To promote appropriate use of bed rails for resident safety. -To reduce entrapment risk by providing appropriate resident assessment . *The Policy was outdated, referring to older federal tags that were no longer in use (i.e. F323 and F221). *The Action Steps included Residents will be assessed for the appropriateness of side rails . B. Based on record review and interview, the provider failed to ensure 2 of 15 sampled residents' medications (17 and 29) had been accurately recorded on the MDS. Findings include: 1. Review of the Long-Term Care Survey Process revealed resident 17 had an MDS indicator for anticoagulation use. Review of resident 17's EMR revealed: *On 7/24/23 a physician's order was received for Aspirin EC (enteric coated) tablet delayed release 81 milligrams (mg) take one tablet daily. *The MDS dated [DATE] at 2:00 p.m. coded as an anticoagulant by MDS coordinator D. 2. Review of the Long Term Care Survey Process revealed resident 29 had an MDS indicator for anticoagulation use. Review of resident 29's EMR revealed: *A 10/2/23 physician's order was received for Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth in the morning. -The medication was related to his Arteriosclerotic heart disease. *His MDS dated [DATE] coded as a anticoagulant by MDS coordinator D. *A review of his physician orders from his 10/2/23 admission to 1/4/24 revealed no anticoagulant medication had been ordered. Interview on 1/4/24 at 9:55 a.m. with DON B and MDS coordinator D revealed they had incorrectly coded the medications as anticoagulants. 8. Observation on 1/2/24 at 3:04 p.m. of resident 16's room revealed: *She was not in her room. *There were bed rails on both sides of her bed. Interview on 1/2/24 at 3:32 p.m. with resident 16 revealed she had requested the bed rails to aid in repositioning herself. Review of resident 16's EMR revealed: *She was admitted on [DATE]. *Her BIMS was scored at 14 which indicated she was cognitively intact. *Her Informed Consent for use of Bed Rails documented Partial rail recommended at all times when resident is in bed and was signed by the resident. *Physician ordered, May have bilateral ½ rails for bed mobility on 10/11/23. *Her 12/4/23 Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 12/5/23 which documented the following: *She had expressed a desire to have the bed rails for her safety and comfort. *[Resident 16's first name] uses bilateral top quarter rails for bed mobility, body positioning and getting in and out of bed. She always locks the brakes on her wheelchair and pivot transfers from her bed to her chair and chair to bed. *The following MDS assessments documented in section P Restraints and Alarms her bed rails as a restraint used daily: -7/31/23 admission assessment. -10/9/23 quarterly review assessment. 9. Observation on 1/2/24 at 3:51 p.m. of resident 18's room revealed: *He was not in his room. *There were two half bedrails on his bed. Interview on 1/4/23 at 8:55 a.m. with resident 18 revealed he used the bed rails for repositioning when in bed. Review of resident 18's EMR revealed: *He was admitted on [DATE]. *His BIMS on 7/25/23 was scored at 11 which indicated he was moderately cognitively impaired. *His Informed Consent for Use of Bed Rails documented Partial rail recommended at all times when resident is in bed and was signed by the resident on 10/16/23. *A physician order May use side rails for bed mobility, body positioning, and transferring in/out of bed on 9/14/22. *His 10/23/23 Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 10/24/23 which documented: -He had expressed a desire to have the bed rails for his safety and comfort. -[Resident's first name] uses bilateral half rails for bed mobility, positioning and getting in and out of bed. The rails help to keep some of his independence. *The following MDS assessments were documented in section P Restraints and Alarms his bed rails as a restraint used daily on the following: -2/6/23 quarterly review assessment. -5/1/23 quarterly review assessment. -7/24/23 annual assessment. 6. Observation and interview on 1/3/24 at 11:12 a.m. with resident 12 regarding his bed rails revealed he used the two half bed rails to reposition himself. Review of resident's 12 (EMR) revealed: *On 9/9/22 a physician's order was written for the use of the bed rails for mobility. *He had been assessed quarterly for the use of the bed rails. *No consent for the bed rails was located in his EMR. *On 10/16/23 his MDS was signed by MDS coordinator D coding section P bed rail as a restraint used daily. 7. Observation and interview on 1/3/24 at 11:36 a.m. with resident 27 regarding his bed rails revealed he used the bed rails to reposition himself. Review of resident 27's EMR revealed: *On 7/17/23 a physician's order was written for the use of the bed rails for mobility. *He had signed a consent for the bed rail use. *He had been assessed for the of bed rail use. *On 12/26/23 his MDS was signed by MDS coordinator D coding section P bed rail as a restaint used daily. Interview on 1/2/24 at 2:15 p.m. with MDS coordinator D regarding restraint use revealed she was unsure if the bed rails should have been coded as a restraint or not, and she had coded the bed rails as a restraint. A. Based on observation, record review, and interview, the provider failed to ensure 11 of 15 sampled residents (2, 11, 12, 13, 16, 17, 18, 23, 27, 28, and 29) with bed rails had them accurately recorded on the Minimum Data Set (MDS). Findings include: 1. Observation on 1/3/23 at 9:15 a.m. of resident 2 revealed: *He was in his room, lying on his bed with partial bed rails on both sides of his bed. *He did not respond to verbal stimuli but remained in bed with his eyes closed. Interview on 1/3/24 at 9:21 a.m. with certified medication aide (CMA) J regarding resident 2 revealed he: *Had left-hand paralysis. *Required staff assistance for all his care. *Used the bed rails to help turn himself in bed. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 12/4/23 Brief Interview for Mental Status (BIMS) was scored at an 8, which indicated he was cognitively moderately impaired. *His Informed Consent for Use of Bed Rails documented Partial rail recommended at all times when resident is in bed and was signed on 4/12/23 by his wife. *A 10/3/23 physician order stated May use bilateral top quarter rails for bed mobility, body positioning and to aid in turning right to left for incontinence cares. *His Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 12/5/23 which documented: -He had expressed a desire to have the bed rails for his safety and comfort. -[Resident 2's first name] uses bilateral top quarter side rails to aid in bed mobility with staff assistance, positioning, and turning right to the left with staff assistance for incontinence care and to place lift sling under him for transfers with the mechanical full body lift. The rails add a level of independence for [resident's first name]. *The following MDS assessments documented in section P Restraints and Alarms his bed rails as a restraint that was used daily on the following: -4/20/23 admission assessment. -5/25/23 readmission assessment. -8/14/23 quarterly review assessment. -9/29/23 readmission assessment. -12/4/23 quarterly review assessment. 2. Observation and interview on 1/2/24 at 5:07 p.m. with resident 11 in her room revealed: *She had worked at the facility for 30 years as a licensed practical nurse (LPN). *She was admitted to the facility 5 years ago. *She stated the bed rails on her bed did not restrain her, but instead, she used the bed rails to assist her with turning in bed and getting in and out of bed. Review of resident 11's EMR revealed: *She was admitted on [DATE]. *Her 11/19/23 BIMS was scored at 15, which indicated she was cognitively intact. *Her Informed Consent for Use of Bed Rails documented 1/2 partial rail recommended at all times when resident is in bed and she had signed the form on 12/12/18. *A 9/9/22 physician order stated May use side rails for bed mobility, body positioning, and transfers in/out of bed. *Her 11/21/23 Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 11/27/23 which documented: -She had expressed a desire to have the bed rails for her safety and comfort. -[Resident 11's first name] is alert and oriented x 3 and has requested siderails to help with bed mobility, body positioning, and getting in and out of bed . *The following MDS assessments were documented in section P Restraints and Alarms her bed rails as a restraint that was used daily for the following: -1/16/23 quarterly review assessment. -4/17/23 quarterly review assessment. -7/10/23 quarterly review assessment. -8/28/23 readmission assessment. -11/19/23 quarterly review assessment. *Her 8/29/23 Physical Restraint care area assessment (CAA) for her 8/28/23 comprehensive readmission assessment revealed: -The CAA was triggered by the MDS assessment coded Bed rail restraint was used daily. -The Evaluation of current restraint use (based on chart documentation, including care plan) did not have any of the eleven factors checked including: --Does not meet regulatory definition of restraint (stop here and check accuracy of MDS item that triggered this CAA). 3. Observation on 1/3/24 at 9:36 a.m. of resident 13 in his room revealed he: *Was in bed covered with a blanket, eyes closed, and snoring. *Had bed rails were elevated on both sides of the bed. Review of resident 13's EMR revealed: *He was admitted on [DATE]. *His 11/20/23 BIMS was scored at 1, which indicated he was cognitively severely impaired. *His Informed Consent for Use of Bed Rails documented 1/2 partial rail recommended at all times when resident is in bed and was signed on 2/19/20 by his wife. *An 8/24/21 physician order stated May use side rails for positioning and transfers. *His 11/21/23 Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 11/27/23 which documented: -He had expressed a desire to have the bed rails for his safety and comfort. -[Resident 13's first name] benefits from top quarter rails for positioning and transferring with the assistance of staff. *The following MDS assessments were documented in section P Restraints and Alarms his bed rails as a restraint that was used daily for the following: -1/2/23 quarterly review assessment. -3/27/23 quarterly review assessment. -6/19/23 quarterly review assessment. -9/4/23 annual assessment. -11/20/23 quarterly review assessment. *His 9/6/23 Physical Restraint CAA for his 9/4/23 comprehensive annual assessment revealed: -The CAA was triggered by the MDS assessment coded Bed rail restraint was used daily. -The Evaluation of current restraint use (based on chart documentation, including care plan) did not have any of the eleven factors checked including: --Does not meet regulatory definition of restraint (stop here and check accuracy of MDS item that triggered this CAA). 4. Observation and interview on 1/3/24 at 9:01 a.m. with resident 28 and her husband revealed: *Resident 28 had bed rails on both sides of her bed. *Resident 28 responded with limited speech and struggled to express herself, looking at her husband to answer the questions. *Resident 28's husband stated the bed rails did not stop his wife from getting up out of bed but instead helped her to get in and out of bed. Review of resident 28's EMR revealed: *She was admitted on [DATE]. *Her 11/6/23 BIMS was scored at 3, which indicated she was cognitively severely impaired. *Her Informed Consent for Use of Bed Rails documented 1/2 partial rail recommended at all times when resident is in bed and was signed on 8/23/23 by her son and power of attorney. *A 10/16/23 physician order stated May have bedrails to aid in mobility and repositioning. *Her 11/6/23 Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 11/27/23 which documented: -She had expressed a desire to have the bed rails for her safety and comfort. -[Resident 28's first name] uses bilateral top quarter rails for bed mobility, positioning, and getting in and out of bed. *Her 11/6/23 quarterly review MDS assessment documented in section P Restraints and Alarms that her bed rails were a restraint that were used daily. 5. Observation on 1/2/24 at 3:27 p.m. with resident 29 in his room revealed: *He was sitting in a recliner in his room. *His speech was limited. *He had bed rails on each side of his bed. Review of resident 29's EMR revealed: *He was admitted on [DATE]. *His 12/18/23 BIMS was scored at 6, which indicated he was cognitively severely impaired. *His Informed Consent for Use of Bed Rails documented 1/4 partial rail recommended at all times when resident is in bed and was signed on 10/2/23 by his daughter and power of attorney. *A 10/19/23 physician order stated Resident may have Bedrails to aid in bed mobility and repositioning. *His Bed Rail/Assist Bar Evaluation was signed by MDS coordinator D on 12/20/23 which documented: -He had expressed a desire to have the bed rails for his safety and comfort. -[Resident 29's first name] uses bilateral quarter top rails for bed mobility, body positioning, and getting in and out of bed. *His 12/18/23 quarterly review MDS assessment documented in Section P Restraints and Alarms that his bed rails were a restraint that was used daily. Interview on 1/4/24 at 9:55 a.m. with director of nursing (DON) B and MDS Coordinator D regarding coding of physical restraints on the MDS and CAA for Physical Restraints revealed: *The initial Resident Matrix provided to the survey team on 1/2/24 had identified 23 of the current 30 residents who had a physical restraint in use. *Both DON B and MDS Coordinator D agreed: -The 1/3/24 evaluations of current residents' bedrail use had not met the regulatory definition of a physical restraint. -They had made mistakes completing the MDS assessments for residents that were using bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview record review, and policy review, the provider failed to develop a comprehensive person-centered care plan regarding respiratory care for 1 of 13 sampled residents' (16) care plans reviewed. Findings include: 1. Interview on 11/15/22 at 9:39 a.m. with resident 16 in her room revealed she: *Was admitted to the facility on [DATE] and was there for rehabilitation and therapy services. *Had an oxygen concentrator machine. *Only used the oxygen concentrator at night. Review of resident 16's care plan dated 9/16/22 revealed there was no focus area or interventions regarding her use of an oxygen concentrator machine. Interview on 11/16/22 at 4:30 p.m. with director of nursing B about care plans revealed: *She was also the Minimum Data Set coordinator and developed resident care plans. *Oxygen therapy was normally something they would have put on the care plans. *She was unaware that resident 16's care plan had not included her use of oxygen at night. Review of the provider's 10/12/17 Baseline Care Plan policy revealed: *The policy stated: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. *Under the Policy Explanation and Compliance Guidelines section: -1. The baseline care plan will . --b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to . ---i. Initial goals based on admission orders. ---ii. Physician orders. ---iii. Dietary orders. ---iv. Therapy services. ---v. Social services. ---vi. [Preadmission screening and resident review] recommendation, if applicable. -2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. --b. Interventions shall be initiated that address the resident's current needs including . ---iii. Any special needs such as for [intravenous] therapy or wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to revise 1 of 13 sampled residents' (2) care plans reviewed after a significant change assessment had been completed to accurately reflect the current status of the resident. Findings include: 1. Review of resident 2's annual Minimum Data Set (MDS) assessment from 7/12/22 revealed he: *Had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. *Was independent with no setup assistance or help from staff with activities like bed mobility, transferring from surface to surface, walking, locomotion off the unit, dressing, toilet use, and personal hygiene. *Was independent with eating after setup assistance from staff. Review of resident 2's significant change MDS assessment dated [DATE] revealed he: *Had a BIMS score of 3, indicating severe cognitive impairment. *Required extensive assistance with the help of two or more people for activities like bed mobility, transferring from surface to surface, dressing, and toilet use. *Required extensive assistance with the help of one person for locomotion on and off the unit. *Required limited assistance with the help of one person for activities like eating and personal hygiene. Review of resident 2's care plan revealed: *There was a focus area of The resident has an [activities of daily living] (ADL) self-care performance deficit [related to] delayed mental status, which was last revised on 2/17/21. *The interventions included: -AM ROUTINE: The resident preferred dressing/grooming routine is to take his time getting dressed and ready for the day. Offer assistance, but usually independent with ADL's. Last revised on 6/23/21. -BATHING/SHOWERING: The resident is able to wash himself once he is assisted into the tub/shower. Limited assist of one. Last revised on 7/8/21. -BED MOBILITY: The resident is independent. May use side rails per [doctor's] order for bed mobility, body positioning, and transferring in/out of bed. Last revised on 9/15/22. -DRESSING: Allow sufficient time for dressing and undressing. Independent with dressing. Last revised on 6/23/21. -ORAL CARE ROUTINE . Resident is independent with oral cares. Last revised on 6/23/21. -PERSONAL HYGIENE ROUTINE: The resident is independent with hygiene. Last revised on 6/23/21. -TOILET USE: The resident is independent with toileting. Continent of bowel and usually continent of bladder. Wears pull up for stress incontinence at times. Last revised 6/23/21. -TRANSFER: The resident is independent. Self propels in a wheelchair about the facility. Last revised on 10/17/22. Interview on 11/15/22 at 3:03 p.m. with director of nursing B revealed: *Resident 2 had a significant decline in independence and behavior after he returned from a therapeutic family leave this past summer. *He had been taken to the emergency room on several occasions due to his significant behavior changes. *Several different medical tests were completed to determine a cause of the behavior change and physical decline, but they were not able to pinpoint the root cause. *He was now dependent on staff for dressing, toileting, transferring, and he no longer was walking on his own. Continued interview on 11/16/22 at 4:30 p.m. with director of nursing B about resident 2's care plan revealed: *She thought she had revised his care plan to reflect that he was no longer independent with ADL's. *It was their normal process to review care plans with each quarterly MDS assessment and make revisions as needed. A request was submitted on 11/16/22 at 10:50 a.m. for a care plan policy. The provider delivered a policy titled Care Planning - Interdisciplinary Team. The policy explained which individuals should have been involved in the care planning process. The policy did not indicate when or how often care plans should have been reviewed and revised.

2. Review of resident 22's electronic and paper medical record revealed: *There was a change in skin notification sent to resident 22's primary care provider on 11/5/22 regarding blisters on his fingers. *The note read, Resident has large blister on [left] pinky finger and small popped blister on [left] ring finger. Blisters cleaned [with] soap [and] water. Triple [antibiotic ointment] placed on popped blister [and] covered [with] bandaid. Pinky blister covered loosely. Resident stated blister came from hot pizza. Review of resident 22's care plan revealed: *A new focus area of Risk for Injury/burns as I have decreased sensation to my fingers and toes. I drink coffee and my potential for spilling it was added on 11/7/22. *The goal read as follows: I will not receive any burns/blisters from hot liquids/foods through next review. 11-12-22- not met as I received a burn to my left index [finger] and to my left thumb. New goal- my areas to my left and right hand will heal without any infections, I will state that my pain is well controlled to my hands, and I will not have any further burns to my hands through next review. Interview on 11/15/22 at 3:11 p.m. and 11/16/22 at 4:46 p.m. with DON B about resident 22 revealed: *He was blind and had decreased sensation in his fingers and toes due to complications with diabetes. *They noticed he had blisters on his fingers on 11/7/22, which worsened, and he developed more blisters on 11/12/22. *He went to the clinic to see his primary care provider for wound management recommendations on 11/8/22 and 11/16/22. *Staff think he may have burned his fingers on a hot pizza box or by spilling hot liquids. *She was not aware that an incident like that was supposed to be reported to the SD DOH. Review of the provider's March 2017 Accidents and Incidents-Investigating and Reporting policy revealed: *The nurse supervisor/charge nurse and/or the department director or supervisor would complete a report of incident/accident form and submit the original to the director of nursing (DON) services within 24 hours of the incident or accident. *The DON would ensure that the administrator received a copy of the report of incident/accident form for each occurrence. *The policy had not identified reportable incidents or accidents should have been reported to the SD DOH. Based on record review, interview, and policy review, the provider failed to ensure the South Dakota Department of Health (SD DOH) had been notified of incidents that caused physical harm for two of two sampled residents (19 and 22). Findings include: 1. Review of resident 19's medical record revealed: *On 8/2/22 by an unknown author: *A physician from (name of facility) called and gave report to the nurse on resident 19. He: -Was able to return to the facility. -Had steri-strips over his right eye. -Had two staples on his head. -Had a fractured nose. Interview on 11/16/22 at 9:30 a.m. with director of nursing (DON) B revealed: *Resident 19 had a fall on 8/2/22. *He did seek outside medical attention. *It was her responsibility to notify the SD DOH for reportable incidents. *She had overlooked that incident. Interview on 11/16/22 at 3:32 p.m. with administrator A revealed: *The DON was responsible for notifying the SD DOH for reportable incidents. *It was her expectation it would have been reported. *Their accidents and incidents policy had not given direction for them to notify the SD DOH. *She confirmed their policy had not included guidance to notify the SD DOH.