**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Centers for Medicare & [and] Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual review, medical record review, and interview the facility failed to accurately code a Minimum Data Set (MDS) assessment for oral/dental status for 1 resident (Resident #162) of 25 residents reviewed. The findings include: Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual dated 10/2024, revealed .primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .SECTION L: ORAL/DENTAL STATUS .This item is intended to record any dental problems present in the 7-day look-back period .Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth . Review of the medical record revealed Resident #162 was admitted to the facility on [DATE] with diagnoses including Dementia, Generalized Anxiety, Major Depressive Disorder, and Fracture for Lower End of Right Femur. Review of a nursing admission baseline health and history assessment for Resident #162 dated 12/31/2024, revealed the resident was edentulous (no natural teeth). Review of an admission MDS assessment for Resident #162 dated 1/7/2025, revealed .No natural teeth or tooth fragment(s) (edentulous) . was documented as .no ., which indicated Resident #162 had natural teeth. During an observation on 1/21/2025 at 11:00 AM, revealed Resident #162 was edentulous. During an observation and interview on 1/23/2025 at 2:20 PM, Licensed Practical Nurse (LPN) B confirmed Resident #162 was edentulous. During an interview on 1/23/2025 at 3:50 PM, the Director of Nursing (DON) confirmed the MDS assessment for oral/dental status was inaccurate for Resident #162.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interviews the facility failed to document post dialysis assessments for 1 resident (Resident #20) of 1 resident reviewed for dialysis. The findings include: Review of the facility's policy titled, Dialysis, revised 5/6/2021, revealed .The facility staff will provide immediate monitoring and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Dependence on Renal Dialysis, Hypertension, Chronic Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed Resident #20 received dialysis. Review of a comprehensive care plan dated 12/20/2019, revealed Resident #20 had a care plan .dialysis r/t [related to] End Stage Renal Failure .I [Resident #20] have a central line for dialysis in my right carotid [artery-carries blood] .dialysis cares for shunt site, staff and dialysis monitors site .Observe/document/report to MD [medical doctor] PRN [as needed] any s/sx [signs/symptoms] of infection to access site: Redness, Swelling, warmth or drainage . Review of the nursing progress notes for Resident #20 from 1/1/2025-1/23/2025 revealed no documentation to show the resident's dialysis catheter site had been assessed/monitored for bleeding upon return to the facility after dialysis treatments. During an observation on 1/23/2025 at 2:40 PM, revealed Resident #20's dressing covering the dialysis catheter access site was dry and intact. During an interview on 1/23/2025 at 3:50 PM, the Director of Nursing (DON) stated staff were expected to assess dialysis catheter access sites for bleeding post dialysis treatment. The DON confirmed post dialysis assessments had not been documented when Resident #20 returned to the facility after dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and interviews the facility failed to ensure expired supplies were not available for resident use for 2 medication storage rooms of 4 medication storage rooms observed. The findings include: Review of the facility's policy titled, Medication Administration Guidelines, dated [DATE], revealed .The expiration/beyond use date .must be checked . During an observation on [DATE] at 9:55 AM, of the 2nd floor north medication storage room with Registered Nurse (RN) C revealed: *1-20 gauge (G) X (by)1 ¼ inch intravenous (IV) catheter with expiration date of [DATE]. *1-20 G X 1 ¼ inch IV catheter with expiration date of [DATE]. *5-20 G X 1 ¼ inch IV catheters with expiration date of [DATE]. During an interview on [DATE] at 10:15 AM, RN C confirmed the IV catheters were expired.During an observation on [DATE] at 1:16 PM, of the 3rd floor medication storage room with RN A revealed: *8-0.97 ounce individual packets of nutrition powder with expiration date of [DATE]. *27-blue top lab tubes with expiration date of [DATE]. *3-18 G X 1 ¼ inch IV catheters with expiration date of [DATE]. *2-20 G X 1 ¼ inch IV catheters with expiration date of [DATE]. During an interview on [DATE] at 1:42 PM, RN A confirmed the nutrition powder, lab tubes, and IV catheters were expired. During an interview on [DATE] at 3:00 PM, the Director of Nursing (DON) confirmed the nutrition powder, lab tubes, and IV catheters were expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review and interview the facility failed to develop a comprehensive care plan for placement of a midline catheter for one Resident (#8) of 3 residents reviewed. The findings included: Review of the facility's policy titled Care Plan, Comprehensive Person-Centered, dated 6/13/2022 revealed .the facility will ensure that a comprehensive, person-centered care plan that is consistent with the resident's rights, needs, and choices is developed and implemented . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Emphysema, Anxiety Disorder, and Chronic Respiratory Failure. Review of a comprehensive care plan dated 4/18/2024, revealed the midline catheter had not been included on the care plan. Review a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an interview on 10/31/2024 at 2:15 PM, the Administrator stated a care plan was not developed for [Resident #2] to include a midline placement, observation, and monitoring. The Administrator confirmed the facility failed to follow their policy for a comprehensive care plan.

Based on facility policy review, the Center for Disease Control (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections review, medical record review, and interview the facility failed to obtain a physician's order for dressing changes for a midline intravenous (IV) catheter, failed to ensure daily assessments of the midline IV site were completed, and failed to change the dressing for 1 resident (Resident #2 ) of 3 residents reviewed for IV therapy. The findings included: Review of the facility policy titled Midline Dressing Changes, revised 12/30/1899 [the Administrator confirmed revision date was error] revealed .To preform, using sterile technique, a Midline dressing change every 7 days and as needed if the dressing becomes soiled, loose, or saturated .Document in care manager [electronic medical record] the procedure, assessment of site, and how patient tolerated procedure. Review of the Summary of Recommendations Infection Control from the Center of Disease Control dated 2/28/2024, revealed replace dressings used on short-term CVC [central venous catheter]sites at least every 7 days for transparent dressings . Review of the Medication Administration Record for Resident #2 dated 4/1/2024-4/30/2024, revealed antibiotic 500 mg [milligrams] intravenously one time a day start date 4/18/2024 at 9:00 AM, stop date 4/22/2024. Antibiotic 1 gm [gram] intravenously two times a day start date 4/22/2024 at 9:00 PM, stop date 4/25/2024. Steroid (a medication used to treat inflammation) 40 mg intravenously two times a day start date 4/17/2024, end date 4/19/2024. Steroid 20 mg intravenously every 12 hours start date 4/19/2024, stop date 4/22/2024. Steroid 20 mg intravenously two times a day start date 4/22/2024, stop date 4/25/2024. Medications were documented administered as ordered. Review of the Treatment Administration Record for Resident #2 dated 4/1/2024-4/30/2024, revealed 4/18/2024 .Okay for midline . No entries for observation or monitoring midline catheter, and no entries for midline catheter dressing changes had been documented. Review of the Nurse's Note for Resident #2 dated 4/18/2024 at 11:45 PM, revealed .Continue on IV antibiotic and [steroid] for pneumonia. No signs of adverse effects noted. Midline right upper arm is patent and flushes well, no redness or swelling present, dressing dry and intact . Review of the Nurse's Note for Resident #2 dated 4/22/2024 at 10:40 AM, revealed .Conts [continue] IVABT [intravenous antibiotic treatment] for PNA [pneumonia]. Midline in right arm intact and flushes well . Review of the Nurse's Note for Resident #2 dated 4/23/2024 at 1:52 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Note for Resident #2 dated 4/23/2024 at 10:59 AM, revealed . IV antibiotics and [steroid] for Pneumonia without adverse effects . Review of the Nurse's Note for Resident #2 dated 4/24/2024 at 4:38 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Note for Resident #2 dated 4/25/2024 at 1:32 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Note for Resident #2 dated 4/26/2024 at 12:25 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Notes for Resident #2 dated 4/27/2024-5/1/2024, revealed no documentation related to the midline catheter. Review of the Nurse's Notes for Resident #2 dated 5/3/2024-5/7/2024, revealed no documentation related to the midline catheter. During an interview on 10/30/2024 at 1:15 PM, the Physician stated .I would expect the facility to follow their protocol for dressing changes and monitoring .in this case the patient suffered no harm. There was no signs or symptoms of infection and no negative outcomes .I saw her on 4/22/2024 .if there had been any signs or symptoms of infection the nurses would have called me .the nurses were attentive to her care . During an interview on 10/30/2024 at 3:40 PM, he Infection Preventionist stated .I would have expected the nurse to document the observation and to follow their doctors' orders for dressing changes .best practice guidelines are for the midline dressing to be changed every 7 days or when soiled, however without a physician's order to change the dressing on the MAR there was no documentation the dressing had been changed . During an interview on 10/31/2024 at 2:15 PM, the Administrator stated the dressing should be changed every 7 days. During the nurses orientation/training they are given instruction/training that a midline is to be flushed every 12 hours and as needed. The Administrator confirmed there was no documentation the midline dress had been changed or monitored per policy.

Based on facility policy review, interview, review of personnel records, staff education, and staff competencies, the facility failed to ensure qualified staff completed tasks within their scope of practice for 1 of 7 staff reviewed for competency. The findings include: Review of a facility policy titled Blood Glucose Monitoring-Using the Accu-Check, dated 1/26/2023, revealed .testing is to be performed by trained personnel. Trained personnel may include a licensed nurse, perfusionist, laboratory personnel and ancillary staff members . Review of a facility document Position Description/Competency Based Evaluation Nursing Assistants, undated revealed no documentation or competency for preforming blood glucose level. Review of the Certified Nursing Assistant (CNA) E personnel file revealed no documentation of education/training for obtaining blood glucose level. The CNA had received a termination notice on 2/15/2024 for obtaining a patients blood glucose without proper training. Review of the Licensed Practical Nurse (LPN) F personnel file revealed the LPN had been terminated for asking a CNA to obtain a patient's blood glucose level. LPN F had not followed the facility policy. During an interview on 10/24/2024 at 8:10 AM, the Risk/Facility Compliance Officer stated the previous Administrator #2 was notified by a CNA that LPN F was allowing CNA E to perform blood sugars on residents. An investigation was conducted and a determination to terminate both employees was based on (LPN F's) own admission that she had allowed CNA E to perform duties out of her scope of practice. During an interview on 10/29/2024 at 8:30 AM, LPN F stated .I let her [CNA E] do one finger stick for me while I was in the room .I admitted to this .she did a finger stick for me one time, I was in the room with her . During an interview on 10/31/2024 at 2:40 PM, the Administrator stated .CNAs are not trained to obtain blood sugars. The nurse admitted to allowing the CNA to obtain a blood sugar and by doing so the CNA practiced outside of her scope of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interviews the facility failed to follow infection control practices during resident care for 1 resident (Resident #8) of 3 residents observed for Enhanced Barrier Precautions. The findings include: Review of the facility's policy titled Infection Control Program, dated 1/18/2024, revealed .the facility will establish and maintain an infection prevention and control program designed to provide a safe sanitary .environment to help prevent the development and transmission of communicable diseases and infections . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Sepsis Unspecified Organism, Venous Insufficiency, Type 1 Diabetes Mellitus, and Anxiety Disorder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Active Diagnoses included Septicemia. Review of a comprehensive care plan for Resident #8 dated 10/23/2024, revealed the resident is under Enhanced Barrier Precautions (EBP). Follow EBP guidelines: gloves and gown required during high-contact activities. Review of the Enhanced Barrier Precautions signage on Resident #8's door directed individuals entering the room to wash their hands before exiting the room. Providers and staff to wear gloves and gown for the following high-contact resident care activities, dressing bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting device care or use, central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing. The signage directed staff not to wear the same gown and gloves for the care of more than one person. During an observation on 10/22/2024 at 8:15 AM, in Resident #8's room, revealed Certified Nursing Assistant (CNA) A entered the residents room with the sit to stand lift. The CNA made contact with the resident and hooked her to the sit to stand lift then the CNA washed her hands, put on gloves, and gown. During an interview on 10/22/2024 at 8:25 AM, CNA A stated she should have washed her hands and put on gloves and gown before touching Patient #8 .I was in a hurry to get her to the commode and I just didn't think .I knew better we have had education more than once on that .that is why I put them on before I transferred her . During the interview the CNA confirmed she had made physical contact with a resident on Enhanced Barrier Precautions without washing her hands or putting on a gown or gloves. During an interview on 10/30/2024 at 3:30 PM, the Infection Preventionist stated .my expectation would have been for the staff to have performed hand hygiene, put on gloves and a gown prior to physical contact with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 5 residents (Resident #14, #27, #29, #15, and #24) of 56 residents reviewed for dignity. The findings include: Review of the facility's policy titled, ATTACHMENT I: Resident Rights Policy, revised 1/2014, showed .Every Facility Resident has the following minimum rights .respect and full recognition of his/her dignity .The Resident has a right to a dignified existence .The resident has the right to personal privacy and confidentiality . Record review showed Resident #14 was admitted on [DATE] with diagnoses including Adult Failure to Thrive, Dysphagia, and Alzheimer's. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 was rarely or never understood and had severe cognitive impairment. During observation on 4/4/2022 at 10:28 AM, revealed signage on the nightstand read, .[Resident #14's initials] .[Resident's room number] .Aspiration [accidentally inhaling liquid or food into the lungs]/Reflux Precautions .feed pt [patient] .Sit upright at 90 deg [degrees] for all intake .Take pills crushed .Date: 9/30/21[2021] . The signage was visible to anyone who entered the residents's room. During observation on 4/4/2022 at 2:44 PM, revealed signage on the nightstand read, .[Resident #14's initials] .[Resident's room number] .Aspiration [accidentally inhaling liquid or food into the lungs]/Reflux Precautions .feed pt [patient] .Sit upright at 90 deg [degrees] for all intake .Take pills crushed .Date: 9/30/21[2021] . The signage was visible to anyone who entered the resident's room. During observation on 4/5/2022 at 9:00 AM, revealed signage was posted above Resident #14's bed that read, .[Resident #14's initials] .[resident's room number] .Aspiration/Reflux Precautions .feed pt .Sit upright at 90 deg for all intake .Take pills crushed .Date: 9/30/21 . The signage was visible to anyone who entered the resident's room. During observation on 4/6/2022 at 8:23 AM, revealed signage was posted above Resident #14's bed that read, .[Resident #14's initials] .[resident's room number] .Aspiration/Reflux Precautions .feed pt .Sit upright at 90 deg for all intake .Take pills crushed .Date: 9/30/21 . The signage was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 10:47 AM, in Resident #14's room, the Clinical Case Manager confirmed the signage was present above Resident #14's bed and was visible to anyone who entered the resident's room. Record review showed Resident #27 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Type 2 Diabetes Mellitus, Vascular Dementia, Peripheral Vascular Disease, Dysphagia, and Cerebral Infarction. Review of an annual MDS assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Observation on 4/4/2022 at 10:32 AM, showed 2 signs posted above Resident #27's bed. The first sign read, . [Resident #27's initials] .[Resident's room number] .Aspiration/Reflux Precautions .Sit upright at 90 deg for all intake .Sit up for 30 minutes following intake .Small bites .Take pills crushed .Avoid meltables .Follow up speech services are recommended .Date: 3/10/22[2022] . The second sign read, CHANGE POSITION OF BED/CHAIR EVERY TWO HOURS . The signage was visible to anyone who entered the resident's room. Observation on 4/5/2022 at 8:35 AM showed 2 signs posted above Resident #27's bed. The first sign read, . [Resident #27's initials] .[Resident's room number] .Aspiration/Reflux Precautions .Sit upright at 90 deg for all intake .Sit up for 30 minutes following intake .Small bites .Take pills crushed .Avoid meltables .Follow up speech services are recommended .Date: 3/10/22[2022] . The second sign read, CHANGE POSITION OF BED/CHAIR EVERY TWO HOURS . The signage was visible to anyone who entered the resident's room. Observation on 4/6/2022 at 8:24 AM showed 2 signs posted above Resident #27's bed. The first sign read, . [Resident #27's initials] .[Resident's room number] .Aspiration/Reflux Precautions .Sit upright at 90 deg for all intake .Sit up for 30 minutes following intake .Small bites .Take pills crushed .Avoid meltables .Follow up speech services are recommended .Date: 3/10/22[2022] . The second sign read, CHANGE POSITION OF BED/CHAIR EVERY TWO HOURS . The signage was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 3:00 PM, the Clinical Case Manager confirmed the signage was present over Resident #27's bed and visible to anyone who entered the resident's room. Record review showed Resident #15 was admitted to the facility on [DATE] with diagnoses including Dementia, and Dysphagia. Review of the admission MDS assessment dated [DATE], showed Resident #15 had a BIMS score of 7, indicating the resident was severely cognitively impaired. During observations on 4/4/2022 at 11:17 AM, 4/4/2022 at 2:10 PM, and 4/5/2022 at 8:47 AM, 1 sign was posted above Resident #15's bed that read, Hard of Hearing .Speak loud +[and] slow or write it down .Thanks! . The signage was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 10:55 AM, in Resident #15's room, the Clinical Case Manager confirmed the signage was present above Resident #15's bed and was visible to anyone who entered the resident's room. Record review showed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Polyneuropathy, Hypertension, and Neuromuscular Dysfunction of the Bladder. Review of the annual MDS assessment dated [DATE], showed Resident #24 had a BIMS score of 8, inidicating the resident was moderately cognitively impaired. During an observation on 4/4/2022 at 11:02 AM, signage was posted above Resident #24's bed that read, 12/15/21 [2021] .[Resident #24's first inital and last name] .Bed position will be alternated to allow her to lay on a different side, to heal her shearing area and prevent more breakdown. Please DO NOT move bed back unless nurse management has instructed to do so . The signage was visible to anyone who entered the resident's room. During an interview on 4/4/2022 at 11:13 AM, Resident #24 stated she was unaware of any signage posted in her room and did not request any signage to be posted. During an observation on 4/5/2022 at 1:25 PM, signage was posted above Resident #24's bed that read, 12/15/21 .[Resident #24's first initial and last name] .Bed position will be alternated to allow her to lay on a different side, to heal her shearing area and prevent more breakdown. Please DO NOT move bed back unless nurse management has instructed to do so . The signsge was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 10:54 AM, in Resident #24's room, the Clinical Case Manager confirmed the signage was present above Resident #24's bed and was visible to anyone who entered the resident's room. During an interview on 4/6/2022 at 10:44 AM, the Clinical Case Manager stated it was the expectation of the facility that resident medical information be communicated to staff members via verbal report and on the care plan. The Clinical Case Manager stated resident medical information was not to be visibly posted unless requested by the resident or family. During an interview on 4/6/2022 at 1:44 PM, the Administrator confirmed no documentation was available to show Residents #14, #27, #29, #15, and #24 or their families had requested any signage to be placed in their rooms. Record review showed Resident #29 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Gastroesophageal Reflux Disease, Paranoid Schizophrenia, and Dysphagia. Review of Resident #29's annual MDS assessment dated [DATE], showed the resident was rarely or never understood and had severe cognitive impairment. During an observation on 4/4/2022 at 10:30 AM, showed a sign posted above the head of the resident's bed .aspiration precautions .please do not lay flat . The signage was visible to anyone who entered the room. During an interview and observation on 4/4/2022 at 3:05 PM, Certified Nursing Assistant (CNA) #1, in Resident #29's room, stated the sign above the head of the resident's bed stated the resident required aspiration precautions and the head of the bed was to be raised at all times. The signage was visible to anyone who entered the room. During an observation on 4/6/2022 at 8:59 AM, showed a sign posted above the head of Resident #29's bed .aspiration precautions .please do not lay flat . The signage was visible to anyone who entered the room. During an interview and observation on 4/6/2022 at 11:00 AM, in Resident #29's room, the Clinical Case Manager confirmed the signage was present above Resident #29's bed and was visible to anyone who entered the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, and observation, the facility failed to obtain a signed consent indicating the potential risks and benefits for the use of a restraint from the resident's representative prior to the use of a restraint and failed to document the monitoring and supervision provided during the use of a restraint to check ever 30 minutes and release and reapply every 2 hours for toileting and range of motion for 1 resident (Resident #2) of 1 resident reviewed for restraint use. The findings include: Review of the facility policy titled, Restraints, Use of, revised 2/17/2020, showed .The following safety guidelines shall be .documented while a resident is in restraints .A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel .Restrained residents must be repositioned at least every two (2) hours on all shifts .Residents and/or surrogate /sponsor shall be informed about the potential risks and the benefits of all options under consideration, including the use of restraints, and the alternatives to restraint use evidenced by signed consent .Documentation regarding the use of restraints shall include .Observation, range of motion and repositioning flow sheets .Direct monitoring and supervision during the use of restraints . Record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Impulse Disorder, Paranoid Personality Disorder, Bipolar Disorder, Generalized Anxiety Disorder, Restlessness and Agitation, Insomnia, and Dementia with Behavioral Disturbance. Review of Resident #2's Physician's Telephone Order dated 1/6/2020, showed .May use seat belt on w/c [wheelchair] for safety and proper positioning, [check] Q [every] 30 min [minutes] release Q 2 hrs [hours] and PRN [as needed] . Review of Resident #2's Nurse's progress note dated 1/6/2020, showed .Verbal Consent for seatbelt on wheelchair for safety, family consent obtained with witness . Record review showed no documentation the facility had obtained a signed consent including the potential risks and benefits of the use of the restraint from the resident's representative. Review of Resident #2's care plan dated 1/6/2020, showed .I may use a seat belt while I am in wheelchair . as the least restrictive means to provide safety and positioning .check seat belt every 30 minutes, release and reapply every 2 hours for toileting and rom [range of motion] and as needed . review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The resident used a wheelchair for mobility and used a restraint daily. Review of Resident #2's quarterly MDS assessment dated [DATE], showed a BIMS score of 00, indicating the resident had severe cognitive impairment. The resident used a wheelchair for mobility and used a restraint in the chair daily. Record review showed no documentation Resident #2 had been monitored or supervised during the use of the seat belt restraint. During an interview on 4/4/2022 at 2:17 PM, Certified Nursing Assistant (CNA) #4 stated she was unsure if the seat belt was used when Resident #2 was seated in the wheelchair was a restraint. The CNA stated the resident was able to self-release the seat belt at times, but she was unsure if the resident was able to self-release the seat belt upon command. The CNA stated the resident was checked frequently while up in the wheelchair and provided assistance with toileting every 2 hours. During an interview on 4/4/2022 at 2:28 PM, Licensed Practical Nurse (LPN) #2 stated Resident #2 did not have a restraint. The LPN stated the resident did use a seat belt when she was seated in her wheelchair, but it was not a restraint. The LPN confirmed she did not document monitoring or supervision provided to the resident while the seat belt was in use .I've never documented anything . but stated the resident was monitored frequently and assited with toileting. During an observation of Resident #2 and interview with the MDS Coordinator on 4/5/2022 at 2:05 PM, showed Resident #2 seated in the wheelchair in the hallway with a seat belt in use. The MDS Coordinator confirmed Resident #2 used a seat belt restraint when she was seated in the wheelchair and the resident was unable to release the seat belt upon command. During an interview on 4/6/2022 at 8:18 AM, the Administrator confirmed the facility did not have documentation of the monitoring or supervision the facility was providing for Resident #2 for the use of the seat belt restraint. The Administrator stated .the staff know to do it [monitor the resident] . During an interview on 4/6/2022 at 9:01 AM, CNA #5 stated she did not know if the seat belt Resident #2 used when she was seated in the wheelchair was a restraint. The CNA stated the staff did observe the resident when she was seated in the wheelchair .we just visually keep an eye on her . and stated incontinence care was provided every 2 hours or more often as needed. During an interview on 4/6/2022 at 9:11 AM, Registered Nurse (RN) #1 confirmed the resident was monitored when she was seated in the wheelchair, but the facility did not have documentation of the monitoring that was provided to the resident for the restraint. During an interview on 4/6/2022 at 1:58 PM, the Clinical Case Manager, confirmed the facility had not documented the restraint monitoring and supervision for Resident #2 and a signed consent had not been obtained prior to the use of the restraint for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician order for a fluid restriction for 1 resident (Resident #12) of 3 residents reviewed for fluid restrictions. The findings include: Review of the facility's policy titled, Medication Administration, revised 10/14/2015, showed .be sure to observe any fluid restriction ordered by the physician . Review of the facility's policy titled, Intake & Output, revised 9/26/2013, showed .resident has a flow sheet maintained by the nurse. The purpose of which is to monitor fluid intake .C.N.A.s [Certified Nurse Assistants] record in cc's [cubic centimeter-equivalent to milliliters] the amounts of intake residents receive each meal .Nurses take the information .and record it on the flow sheet . Record review showed Resident #12 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Acute Myocardial Infarction, Atherosclerotic Heart Disease, Edema, and Essential Hypertension. Review of a Physician's Telephone Order dated 10/22/2021, showed .1500 fluid restriction . Review of Resident #12's Comprehensive Care Plan revised 10/23/2021, showed .resident has fluid overload or potential fluid volume overload r/t [related to] .[history of] edema .fluid restrictions of 1500 ml [milliliters] daily . Review of the intake and output record dated 1/1/2022-1/31/2022, showed 12 out of 31 days, the resident's intake exceeded the 1500 cc fluid restriction by the amounts that follow: -1/1/2022- fluid intake exceeded by 140 cc -1/6/2022- fluid intake exceeded by 220 cc -1/7/2022- fluid intake exceeded by 500 cc -1/10/2022- fluid intake exceeded by 150 cc -1/11/2022- fluid intake exceeded by 120 cc -1/16/2022- fluid intake exceeded by 10 cc -1/17/2022- fluid intake exceeded by 60 cc -1/19/2022- fluid intake exceeded by 530 cc -1/20/2022- fluid intake exceeded by 420 cc -1/24/2022- fluid intake exceeded by 300 cc -1/29/2022- fluid intake exceeded by 540 cc -1/30/2022- fluid intake exceeded by 420 cc Review of the intake and output record dated 2/1/2022-2/28/2022, showed 17 out of 28 days, the resident's intake exceeded the 1500 cc fluid restriction by the amounts that follow: -2/2/2022- fluid intake exceeded by 180 cc -2/3/2022- fluid intake exceeded by 500 cc -2/4/2022- fluid intake exceeded by 440 cc -2/6/2022- fluid intake exceeded by 300 cc -2/8/2022- fluid intake exceeded by 340 cc -2/9/2022- fluid intake exceeded by 240 cc -2/11/2022- fluid intake exceeded by 780 cc -2/12/2022- fluid intake exceeded by 540 cc -2/13/2022- fluid intake exceeded by 380 cc -2/14/2022- fluid intake exceeded by 360 cc -2/16/2022- fluid intake exceeded by 440 cc -2/17/2022- fluid intake exceeded by 420 cc -2/19/2022- fluid intake exceeded by 480 cc -2/21/2022- fluid intake exceeded by 160 cc -2/22/2022- fluid intake exceeded by 120 cc -2/23/2022- fluid intake exceeded by 100 cc -2/27/2022- fluid intake exceeded by 20 cc Review of the intake and output record dated 3/1/2022-3/31/2022, showed 2 out of 31 days, the resident's intake exceeded the 1500 cc fluid restriction by the amounts that follow: -3/7/2022- fluid intake exceeded by 540 cc -3/8/2022- fluid intake exceeded by 320 cc Review of the nurse's notes from 10/22/2021 to 4/6/2022, showed no documentation Resident #12 had any adverse outcome related to the increased fluid intake. Observation on 4/4/2022 at 10:49 AM, showed the Resident #12 sitting in a wheelchair. Further observation showed the resident had no visible swelling. Observation on 4/5/2022 at 3:12 PM, showed the Resident #12 sitting in a wheelchair. Further observation showed the resident had no visible swelling. Observation on 4/6/2022 at 2:00 PM, showed the Resident #12 sitting in a wheelchair. Further observation showed the resident had no visible swelling. During an interview on 4/5/2022 at 7:45 AM, Licensed Practical Nurse (LPN) #4 stated the resident had a physician's order for a 1500 cc fluid restriction. She stated the CNAs track fluid intake after all meals, document the percentage in the computer, and tell the nurse the fluid intake percentage. Continued interview revealed the nurse documents the fluid intake percentage from all meals on the intake and output flowsheet then calculates how much more fluid the resident had remaining in a 24 hour period. During an interview on 4/5/2022 at 8:00 AM, LPN #1 stated when a resident had a fluid restriction order, CNA staff calculated the fluid intake from all meals, documented the percentages, and informed the assigned nurse how many cc's the resident consumed. She stated the nurse documented intake percentages from all meals on an intake monitoring sheet placed with the Medication Administration Record (MAR). Continued interview revealed nursing would calculate the total amount of fluids consumed and the remaining amount of fluids for the 24 hour period. During an interview 4/5/2022 at 8:00 AM, CNA #2 stated when a resident was on a fluid restriction, the CNA staff were responsible for calculating fluid intake from all meals. She stated fluid intake percentages were documented and the assigned nurse was made aware of the totals. During an interview on 4/5/2022 at 2:45 PM, CNA #6 stated she was aware Resident #12 had a fluid restriction. She stated fluid intake percentages were calculated from all meals and reported to the nurse. Continued interview revealed the nurse informs the staff of how much fluid the resident has remaining. During an interview on 4/5/2022 at 3:00 PM, the Dietary Manager stated dietary employees were aware of Resident #12's 1500 cc fluid restriction. He also stated the resident was served 360 cc daily for breakfast, 480 cc daily for lunch, and 240 cc daily for dinner for a total of 1080 cc daily from dietary. During an interview on 4/5/2022 at 3:55 PM, the Director of Nursing (DON) stated her expectation was for the facility to follow physician orders. The DON confirmed the facility failed to follow physician orders regarding fluid restrictions for Resident #12. During a telephone interview on 4/6/2022 at 10:52 AM, Resident #12's physician stated the resident had a fluid restriction and the physician expected the facility to follow his orders. He also stated he conducted an assessesment of the resident monthly and the resident had been stable while at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide water flushes for a resident who received tube feeding (nutrition provided by a tube placed directly into the stomach) per the Physician's order for 1 resident (Resident #42) of 2 residents review for tube feedings. The findings include: Review of the facility policy titled, Feeding, tube feeding, revised 6/14/2016, showed .Dietician will .determine .nutritional needs .The physician will be notified of any recommendations and any orders will be followed . Record review showed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Parkinson's, and Gastrostomy Status. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was rarely or never understood and had severe cognitive impairment. Continued interview showed the resident received nutrition by tube feedings. Review of Resident #42's Physician's Telephone Order dated 3/16/2022, showed .[increase] auto flush [water flush of the feeding tube] to 35cc [cubic centimeters]/ [per] hr [hour] . Review of Resident #42's Supplements Record dated 3/2022, showed .SUPPLEMENTS .Glucerna [type of nutrition provided by a feeding tube] .[with] 30ml [milliliters- equivalent to cubic centimeters] H2O [water] flush . Further review showed no documentation of an update to reflect the 3/16/2022 physician's telephone order to increase the water flush to 35 cc/hour. Review of Resident #42's care plan updated on 3/27/2022, showed .Maintain rate of Glucerna .w/ [with] 35 ml/hour free water [flush] . Review of Resident #42's Supplements Record dated 4/2022, showed .SUPPLEMENTS .Glucerna .[with] 30 ml H2O flush . During an observation on 4/4/2022 at 10:36 AM, showed Resident #42 lying on the bed with Glucerna tube feeding infusing at 80 ml/hour and the water flush infusing at 30 ml/hour. During an observation on 4/5/2022 at 2:08 PM, showed Resident #42 lying on the bed with Glucerna tube feeding infusing at 80 ml/hour and the water flush infusing at 30 ml/hour. During an observation and interview on 4/5/2022 at 2:12 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #42's water flush was infusing at 30 cc/hour. The LPN stated if the facility received a new order, the nurse who received the order was responsible to update the order on the supplement record and change the rate on the feeding pump. LPN #1 confirmed Resident # 42's Supplement Record showed the resident was to receive the water flush at 30 ml/hour. (the physician's order dated 3/16/2022 was for 35 cc/hour) During an interview on 4/5/2022 at 2:23 PM, the Clinical Case Manager (CCM) confirmed Resident #42 had an order dated 3/16/2022 to increase the auto flush to 35 cc/hour. Continued interview confirmed the resident was to receive 35 cc/hour water flush and the resident was not receiving receiving the appropriate amount of water flush.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review showed Resident #32 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Hypothyroidism, Hypertension, Anxiety Disorder, Dementia with Behavioral Disturbance, Dysphagia, and Gastrostomy. Review of the admission Orders dated 2/18/2022, showed .Admitting Diagnosis: New Peg Tube [an artificial external opening into the stomach for nutritional support] .Peg tube (New) .Glucerna 1.2 tube feeding @ [at] 30 ml [milliliters]/hr [hour] [with] end goal rate 55 ml/hr, Flush 35 ml/hr . Review of the Care Plan dated 2/22/2022, showed .tube feeding r/t [related to] decreased oral intake that is insufficient to maintain my nutritional needs .I am dependent with tube feeding and water flushes .See MD [medical doctor] orders for current feeding orders . Review of the PHYSICIAN's TELEPHONE ORDERS dated 2/24/2022, showed an order to increase tube feeding 10 milliliters per shift until initial goal of 65 ml/hr was reached for 22 hours per day. Review of the Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022, showed .PEG Tube feeding Glucerna 1.2 . Further review showed the orders were incomplete and did not show the order for resident's water flushes. Review of the PHYSICIAN'S TELEPHONE ORDERS dated 3/31/2022, showed .Decrease tube feeding to Glucerna 1.2 @ 55 ml/hr . Review of the Physician Recapitulation Orders dated 4/1/2022 - 4/30/2022, showed .PEG T.F. [tube feeding] Glucerna 1.2 . Further review showed the orders were incomplete and did not show the order for the resident's tube feeding water flushes. Observation on 4/4/2022 at 11:06 AM, showed Resident #32 lying in bed with the head of the bed elevated. Resident #32 had Glucerna 1.2 at 55 ml/hr and water flush at 35 ml/hr infusing via PEG tube. During an interview on 4/5/2022 at 8:47 AM, LPN #2 stated Resident #32's current tube feeding orders were Glucerna 1.2 at 55 ml/hr and water flush at 35 ml/hr for 22 hours daily. The LPN confirmed there was no order for the 35 ml/hr water flush listed on Resident #32's Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022. LPN #2 stated the water flush order was listed in the dietary notes .that is what I have been told . During an observation and interview on 4/5/2022 at 3:14 PM, in Resident #32's room, the Clinical Case Manager confirmed Resident #32 had Glucerna at 55 ml/hr and water at 35 ml/hr infusing via PEG tube. The Clinical Case Manager confirmed there was no order for the 35 ml/hr water flush on the Physician's Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022. The Clinical Case Manager stated the 35 ml/hr water flush was ordered on Resident #32's readmission from the hospital on 2/18/2022 and confirmed the order was not placed on the monthly Physician's Recapitulation Orders. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #32's Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022 was not accurate and did not inlclude the 35 ml/hr water flush as ordered by the physician on 2/18/2022. Record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Impulse Disorder, Paranoid Personality Disorder, Bipolar Disorder, Generalized Anxiety Disorder, Restlessness and Agitation, Insomnia, and Dementia with Behavioral Disturbance. Review of Resident #2's Physician's Telephone Order dated 1/6/2020, showed .May use seat belt on w/c [wheelchair] for safety and proper positioning . Review of Resident #2's care plan dated 1/6/2020, showed .I may use a seat belt while I am in wheelchair . Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. Continued review revealed the resident used a restraint in the chair daily. Review of Resident #2's Physician's Recapitulation Orders dated 1/1/2022-1/31/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. Review of Resident #2's Physician's Recapitulation Orders dated 2/1/2022-2/28/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. Review of Resident #2's Physician's Recapitulation Orders dated 3/1/2022-3/31/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. Review of Resident #2's Physician's Recapitulation Orders dated 4/1/2022-4/30/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. During an observation on 4/5/2022 at 2:05 PM, showed Resident #2 seated in the wheelchair in the hallway with a seat belt in use. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #2 had a physician's order for the use of a seat belt to be used when she was seated in a wheelchair. The DON confirmed the facility had not placed the order on Resident #2's Physician's Recapitulation Orders for the months of 1/2022, 2/2022, 3/2022, and 4/2022. Continued interview confirmed the physician recapitulation orders were inaccurate. Record review showed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Parkinson's, and Gastrostomy Status (feeding tube placed directly into the stomach to provide nutrition). Review of Resident #42's Physician's Telephone Order dated 2/9/2021, showed .Glucerna [type of nutrition provided by feeding tube] .@ [at] 80 ml [milliliters]/ [per] hr [hour] [with] H2O [water] flush [flush of the feeding tube] 30 ml/hr Review of Resident #42's Physician's Recapitulation Orders dated 2/1/2022-2/28/2022, showed an order for .Glucerna .@ 80 ml Further review showed the orders were inaccurate and did not have documentation of an order for the water flush to be administered. Review of Resident #42's Physician's Recapitulation Orders dated 3/1/2022-3/31/2022, showed an order for .Glucerna .@ 80 ml . Further review showed the orders were inaccurate and did not have documentation of an order for the water flush to be administered. Review of Resident #42's Physician's Telephone Order dated 3/16/2022, showed .[increase] autoflush [water flush] to 35 cc [cubic centimeter] /hr . Review of Resident #42's Physician's Recapitulation Orders dated 4/1/2022-4/30/2022, showed an order for .Glucerna .@ 80 ml . Further review showed the orders were inaccurate and did not have documentation of an order for the water flush to be administered. During an observation and interview on 4/5/2022 at 2:12 PM, in Resident #42's room, Licensed Practical Nurse (LPN) #1 confirmed the resident had the water flush infusing with the tube feeding. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #42 had a physician's order for a water flush to be administered with the tube feeding. The DON confirmed the facility had not placed the order on the resident's Physician's Recapitulation Orders for the months of 2/2022, 3/2022, and 4/2022. Continued interview confirmed the physician recapitulation orders were inaccurate. Based on medical record review, observation, and interview the facility failed to maintain accurate and complete medical records for 5 residents (Residents #1, #2, #42, #6, and #32) of 19 residents reviewed for medical records. The findings include: Record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Generalized Anxiety Disorder, Anemia, Acute and Chronic Respiratory Failure, Heart Failure, Major Depressive Disorder, Schizophrenia, Impulse Disorder, Pneumonia, and Unspecified Dementia with Behavioral Disturbance. Review of a Physician's Order dated 2/9/2022 for Resident #1 showed the Remeron (Mirtazapine) (anti-depressant medication) was discontinued. Review of a Physician's Recapitulation Order dated 3/2022 for Resident #1 showed Mirtazapine 7.5 milligram (mg) at bedtime continued to be listed on the resident's active orders. During an observation an interview on 4/5/2022 at 2:45 PM, Licensed Practical Nurse (LPN) #1 showed the Mirtazapine for Resident #1 was not available for administration on the medication cart. LPN #1 further stated after a telephone order or a physician's order was received, the order was scanned to the pharmacy and .sometimes I'm not sure if it goes through . Continued interview showed the pharmacy generated the recapitulation orders each month and it was the nurse's responsibility to notify the pharmacy of any medication discrepancies identified on the monthly orders. LPN #1 confirmed the Mirtazapine had been discontinued on 2/9/2022, was incorrectly documented on the 3/2022 monthly recapitulation orders and was not given to the resident after the resident medication was discontinued. During an interview on 4/5/2022 at 2:50 PM, the Director of Nursing (DON) stated the Mirtazapine 7.5 mg at bedtime was discontinued on 2/9/2022 and continued to be listed on Resident #1's 3/2022 active Physician's Recapitulation Orders. Continued interview confirmed the documentation for the discontinued Mirtazapine on the active Physicians Recapitulation Orders was inaccurately documented and the resident did not receive the discontinued medication. Resident #6 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dementia, Anxiety, and Depression. Review of the physician's telephone orders for Resident #6 showed a decrease in daily blood sugar checks, dated 12/10/2020, Decrease Fingersticks (to obtain a blood sugar value) to FBS (fasting blood sugar)/ [and] 4 PM. Review of Resident #6's monthly Physician Recapitulation Orders, dated 4/2022, showed HUMALOG [fast acting insulin] 100 UNITS/ML [mililiter] VIAL INJECT 4-16 UNITS .BEFORE MEALS & [and] AT BEDTIME PER MODERATE DOSE SLIDING SCALE. Continued review showed an order, LANTUS [ long acting insulin] 100 UNITS/ML INJECT 46 UNITS .EVERY DAY. Review of Resident #6's monthly physician's recapitulation orders showed the orders were inaccurate from January 2021 through April 2022 and did not reflect the resident new order for blood sugar checks twice a day. During an interview with Licensed Practical Nurse (LPN) #3 on 4/5/2022 at 3:00 PM, she confirmed each month, when the physician's recapitulation orders were reviewed, the order for blood sugar checks before meals and at bedtime remained on the current recapitulation orders. Continued interview confirmed the inaccurate order was not being followed and the resident's blood sugar was being checked twice a day. Further interview revealed, prior to the beginning of each month, she or another nurse checking recapitulation orders. Continued interview confirmed the order for the long acting insulin every day on the recapitulation orders was incomplete because the order did not specify whether the insulin was to be given in the morning or at bedtime. Interview confirmed the order was incomplete and each month the MAR was set up by the nursing staff to be administered in the early morning because .we know the doctor administers long acting insulin in the morning. During an interview with LPN #1 on 4/5/2022, at 3:15 PM, revealed all telephone orders were scanned to the pharmacy when written. Further interview confirmed this order to reduce the blood sugar checks to 2 times a day was not included in Resident #6 monthly recapitulation orders and the monthly orders continued to inaccurately specify 4 blood sugar checks a day for the sliding scale insulin. Continued interview revealed the resident received 2 blood sugar checks daily. During an interview with LPN #1 and LPN #3 on 4/5/2022 at 3:20 PM, confirmed Resident #6's 2 orders for insulin administration on the Physician's Recapitulation Orders, dated 4/3/2022, were inaccurate. Continued interview confirmed the frequency of administration of the sliding scale insulin was inaccurate and the order was incomplete for the time of day the resident's long acting insulin was to be administered. During an interview with the Pharmacy Director on 4/6/2022 at 9:35 AM, he confirmed the order for Resident #6's long acting insulin administration on the physician orders was incomplete because a time for administration was not specified. Further interview confirmed the order to check the resident's blood sugar 4 times a day and to administer the moderate sliding scale insulin if needed was inaccurate and remained on the monthly Recapitulation Physician Orders (16 months after the physician ordered the blood sugar checks and sliding scale insulin administration to be reduced to twice a day). During a telephone interview with Resident #6's physician on 4/6/2022 at 10:00 AM, he confirmed he understood the resident's monthly recapitulation orders he signed each month were inaccurate and stated, .Appreciate this, we will work on this and make sure it is taken care of properly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of prior survey results, medical record review and interview, the facility failed to maintain compliance with prior plans of correction, in an effort to sustain accurate physician orders and failed to ensure an effective Quality Assurance program that addressed ongoing concerns with physician orders for 4 residents (Residents #1, #6, #32, and #42) of 19 residents reviewed for medical records. The findings include: Review of the facility's plans of correction dated 2/10/2020 included, .3. The DON [Director of Nurses] conducted education with the nursing staff regarding following physician orders, diabetic medication/sliding scale insulin, and treatment administration .random checks of treatment and medication administration orders to ensure compliance with physician orders .findings .reported at the quarterly QAPI [quality assurance performance improvement] meeting with modifications made if indicated , to maintain substantial compliance. The facility defines substantial compliance as a rate of 100% compliance with physician orders of records reviewed . During review of 19 resident's medical records, 4 residents were found with inaccurate physician orders as follows: Record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Heart Failure, Major Depressive Disorder, Schizophrenia, Pneumonia, and Unspecified Dementia with Behavioral Disturbance. During an interview on 4/5/2022 at 2:50 PM, the Director of Nursing (DON) confirmed Resident #1's medication for Mirtazapine 7.5 mg at bedtime was discontinued on 2/9/2022 and continued to be inaccurately listed on the current Physician's Recapitulation Orders. Record review showed Resident #6 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dementia, Anxiety and Depression. Review of the physician's telephone orders for Resident #6 showed a decrease in daily blood sugar checks, dated 12/10/2020, Decrease Fingersticks (to obtain a blood sugar value) to FBS (fasting blood sugar)/4 PM. Review of Resident #6's monthly Physician Recapitulation Orders, dated April 2022 and signed by the physician on 4/3/2022, showed HUMALOG (fast acting insulin) 100 UNITS/ML VIAL INJECT 4-16 UNITS .BEFORE MEALS & AT BEDTIME PER MODERATE DOSE SLIDING SCALE. Continued review showed an order, LANTUS (long acting insulin) 100 UNITS/ML INJECT 46 UNITS .EVERY DAY. During an interview with LPN #3 on 4/5/2022 at 3:00 PM, she confirmed each month, when the Physician's Recapitulation Orders were reviewed, the order for blood sugar checks before meals and at bedtime inaccurately remained on the current orders. Continued interview confirmed the order was not being followed and revealed prior to the beginning of each month, she or another nurse checking recapitulation orders, created a handwritten Moderate Dose Sliding Scale Insulin Medication Administration Record (MAR) used to document blood sugar values and the administration of sliding scale insulin if indicated. Interview confirmed the decrease to 2 times a day fingersticks was on the Sliding Scale Insulin MAR, without a start date included. Continued interview confirmed the order for the long acting insulin every day on the recapitulation order was incomplete due to a morning or bedtime administration was not specified. During an interview with the Pharmacy Director on 4/6/2022 at 9:35 AM, he stated during the monthly pharmacy reviews medication administration records were checked .not currently auditing accuracy of recap (recapitulation) orders . Further interview confirmed the pharmacy wasn't aware of scanned telephone orders not always being entered into the monthly recapulation orders to maintain accurate and current orders. Record review showed Resident #32 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Hypothyroidism, Hypertension, Anxiety Disorder, Dementia with Behavioral Disturbance, Dysphagia, and Gastrostomy. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #32's Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022 did not include the 35 ml/hr water flush [used with tube feeding administration] as ordered by the physician on 2/18/2022. Record review showed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Parkinson's, and Gastrostomy Status (feeding tube placed directly into the stomach to provide nutrition). During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #42 had a physician's order for a water flush to be administered with the tube feeding. The DON confirmed the facility had not placed the order on the resident's Physician's Recapitulation Orders for the months of 2/2022, 3/2022, and 4/2022. Interview with the Quality Director and the Clinical Case Manager, confirmed the facility's prior plans of correction related to accurate medication and treatment orders had not been sustained. Further interview confirmed the facility was aware of the ongoing problems with medication and treatment orders not being included, corrected, or updated on the monthly recapitulation orders. Continued interview confirmed the Quality Assurance program did not have an active plan to address incomplete or inaccurate physician orders.

Based on facility policy review, temperature log review, observation, and interview, the facility failed to maintain an appropriate temperature in the freezer and failed to ensure temperature logs were maintained for the refrigerator and freezer in 1 of 2 nourishment rooms which had the potential to affect 55 of 56 residents in the facility. The findings include: Review of the facility's policy titled, NURSING UNIT STOCK, dated 1/2022, showed .Nursing personnel are responsible for the once daily temperature monitoring of unit refrigerator(s) on a posted temperature sheet .If the refrigeration unit includes a freezer, the temperature in the freezer is also recorded once daily (ideal temperature is 0 [degrees] F [Fahrenheit], but may go as high as 10 [degrees] F in the nursing pantries if food remains solid to touch . Review of the 2nd North Nourishment Room FREEZER TEMPERATURE LOGS dated 4/2022, showed .Please place an X in the appropriate box for freezer temperature readings daily. If temperatures fall outside the gray zone, corrective actions must be taken .Dietary action steps .Check product for thawing and remaining ice crystals. If frozen, move to a working freezer unit. If thawed .discard as appropriate (ice cream, etc [etcetera]) .If the temperature is out of range discard the product and place a sign on the freezer OUT OF ORDER . Further review showed the gray zone included temperatures between -10 degrees F and 10 degrees F. The FREEZER TEMPERATURE LOGS showed an entry on 4/1/2022 of 4 degrees F. Continued review showed no temperature was recorded on 4/2/2022, 4/3/2022, and 4/4/2022. Review of the 2nd North Nourishment Room REFRIGERATOR TEMPERATURE LOGS dated 4/2022, showed .Please place an X in the appropriate box for cooler temperature readings daily . Further review showed an entry on 4/1/2022 of 37 degrees F. Continued review showed no temperature was recorded on 4/2/2022, 4/3/2022, and 4/4/2022. Observation and interview on 4/5/2022 at 10:09 AM, with the Dietary Director, in the 2nd North Nourishment Room, showed the freezer temperature was 16 degrees F. The freezer contained 21- 3 fluid ounce orange sherbet containers. The orange sherbet containers were soft to touch, not frozen solid, and availabel for resident use. The Dietary Director stated the nursing staff was responsible for obtaining and recording daily temperatures for the nourishment room refrigerator and freezer. Nursing staff was to notify the dietary department and maintenance for any freezer temperature reading out of the gray zone (above 10 degrees F). The Dietary Director confirmed no temperature reading had been obtained for the 2nd North Nourishment Room refrigerator or freezer from 4/2/2022 - 4/4/2022 and the current temperature reading in the freezer was 16 degrees F. Further interview with the Dietary Director confirmed the dietary department was unaware of the 2nd North Nourishment Room freezer temperature above 10 degrees F. During an interview on 4/5/2022 at 3:33 PM, the Registered Nurse (RN) Supervisor stated she was unaware who was responsible for obtaining and documenting refrigerator and freezer temperatures on the temperature log. During an interview on 4/6/2022 at 11:05 AM, the Administrator confirmed nursing staff were responsible for obtaining and recording nourishment room refrigerator and freezer temperatures daily. The Administrator confirmed temperatures had not been recorded for the 2nd North Nourishment Room refrigerator and freezer for 3 days from 4/2/2022 - 4/4/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow Physician Orders for wound care and failed to follow Physician Orders for sliding scale insulin for 1 resident (#59) of 3 residents reviewed for wound care and sliding scale insulin. The findings include: Review of the facility's policy titled, Medication Administration, dated 10/20/2018, showed .Medications will be administered only upon the orders of physicians . Resident #59 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Muscle Weakness, and Anxiety Disorder. Review of a Physician Telephone Order dated 12/16/2019, showed .Apply Z-guard [ointment to treat pressure wound] BID/PRN [twice daily and as needed] . Review of a Treatment Flow Sheet dated 12/1/2029-12/31/2019, showed Z-guard had been applied daily 12/16/2019-12/31/2019, and not BID/PRN as ordered. Review of a Treatment Flow Sheet dated 1/1/2020-1/31/2020, showed the Z-guard had been applied daily 1/1/2020, 1/2/2020, 1/3/2020 and 1/6/2020-1/21/2020. And not BID/PRN as ordered. The Z-guard had not been applied on 1/1/2020, 1/4/2020 and 1/5/2020 as ordered. Review of the Weekly Wound Assessment Sheet dated 12/16/2019, showed a sacrum stage II wound, onset 11/2019 measuring 1x (by)1 x 0.1 centimeter (cm). Review of the Weekly Wound Assessment Sheet dated 1/20/2020, showed the wound measured 1 x 1 x 0.1cm and did not increase in size. Observation of the resident on 1/22/19 at 1:30 PM, revealed the resident lying on her back with the head of bed elevated at 30 degrees and an air mattress in place. During an interview on 1/22/2020 at 4:00 PM, the Wound Nurse confirmed the wound care had been provided daily 12/16/2020-12/31/2020 and had been provided daily 1/2/2020, 1/3/2020, and 1/6/2020-1/21/2020. There was no documentation that wound care had been provided to Resident #59 as ordered. During an interview on 1/23/2020 at 8:20 AM, the Director of Nursing (DON) confirmed the facility failed to follow physician orders for wound care for Resident #59. Observation of Resident #59's wound on 1/23/2020 at 9:20 AM, with the Lead Supervisor showed an open area to the sacrum, pink wound bed, with no odor or drainage, and the area was blanchable (skin blanches with pressure). The resident was lying in the bed with an air mattress in place. Review of the Physician Recapitulation Orders for 1/1/2020-1/31/2020 showed, .NOVOLOG [medication to treat Diabetes] .BEFORE MEALS & [AND] AT BEDTIME .LOW DOSE SLIDING SCALE . Review of an Insulin Administration Documentation record dated 1/20/2020 8PM-1/23/2020 5AM showed the resident had a moderate dose sliding scale in place, and not the low dose sliding scale as ordered for Resident #59. The Insulin Administration Documentation record showed the resident had a total of 8 incorrect doses of insulin administered from 1/20/2020-1/23/2020. During an interview on 1/23/2020 at 12:20 PM, the DON confirmed the facility failed to follow physician orders for sliding scale insulin for Resident #59. During an interview on 1/23/2020 at 12:50 PM, Licensed Practical Nurse (LPN) #2 confirmed she failed to administer the correct dose of sliding scale insulin to Resident #59 on 1/22/2020 at 12:00 PM and 5:00PM. During a telephone interview on 1/23/2020 at 2:08 PM, Resident #59's Physician stated the resident used to be on a moderate dose sliding scale and he changed it to low dose sliding scale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Facility policy review, medical record review, and interview, the facility failed to prevent a significant medication error for 1 resident (#59) of 3 residents reviewed for insulin administration. The findings include: Review of the facility's policy titled, Medication Administration, dated 10/20/2018, showed .Medications will be administered only upon the orders of physicians . Resident #59 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Muscle Weakness, and Anxiety Disorder. Review of the Physician Recapitulation Orders for 1/1/2020-1/31/2020 showed, .NOVOLOG [insulin medication to treat Diabetes] .BEFORE MEALS & [AND] AT BEDTIME .LOW DOSE SLIDING SCALE . Review of a blank Insulin Administration Documentation form undated showed: Low Dose Regimen (blood glucose ranges) - Less than 40= initiate hypoglycemia protocol and call MD (Medical Doctor) - 41-50= 0 units - 151-200= 0 units - 201-250= 3 units - 251-300= 4 units - 301-350= 6 units - 351-499= 9 units - Greater than 500= 12 units of insulin and call MD The Moderate Dose Regimen (blood glucose ranges) - Less than 40= initiate hypoglycemia protocol and call MD - 41-150= 0 units -151-200= 4 units - 201-250= 8 units - 251- 300= 10 units -301-350= 12 units - 351-499= 16 units - Greater than 500= 18 units and call MD Review of Resident #59's Insulin Administration Documentation form dated 1/20/2020 at 8PM-1/23/2020 5AM showed Resident #59 had a moderate dose sliding scale in place, and not the low dose sliding scale as ordered. The form showed the following: - 1/20/2020 at 8PM, blood sugar 310, Novolog 10 units administered. The resident was to receive Novolog 6 units as per ordered sliding scale. - 1/21/2020 at 5AM, blood sugar 245, Novolog 8 units administered. The resident was to receive Novolog 3 units as per ordered sliding scale. - 1/21/2020 at 8PM, blood sugar 267, Novolog 10 units administered. The resident was to receive Novolog 4 units as per ordered sliding scale. - 1/22/2020 at 5AM, blood sugar 155, Novolog 4 units administered. The resident was to receive Novolog 0 units as per ordered sliding scale. - 1/22/2020 at 12PM, blood sugar 197, Novolog 4 units administered. The resident was to receive Novolog 0 units as per ordered sliding scale. - 1/22/2020 at 5PM, blood sugar 221, Novolog 4 units administered. The resident was to receive Novolog 3 units as per ordered sliding scale. - 1/22/2020 at 9PM, blood sugar 251, Novolog 10 units administered. The resident was to receive Novolog 4 units as per ordered sliding scale. - 1/23/2020 at 5AM, blood sugar 176, Novolog 4 units administered, The resident was to receive Novolog 0 units as per ordered sliding scale. A total of 8 wrong doses had been administered to Resident #59. The resident did not experience hypoglycemic episodes due to the incorrect doses being administered. During an interview on 1/23/2020 at 12:20 PM, the Director of Nursing confirmed the facility follows the Insulin Administration Documentation record for insulin low dose regimen. The DON confirmed Resident #59 had received 8 incorrect doses of insulin and the facility failed to follow physician orders for sliding scale insulin for Resident #59. During an interview on 1/23/2020 at 12:50 PM, Licensed Practical Nurse (LPN) #2 confirmed she failed to administer the correct dose of sliding scale insulin to Resident #59 on 1/22/2020 at 12:00 PM and 5 PM. During a telephone interview on 1/23/2020 at 2:08 PM, Resident #59's Physician stated the resident used to be on a moderate dose sliding scale and he changed it to low dose sliding scale. The Physician stated there were no adverse side effects to the resident due to the incorrect insulin doses administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a physician had signed the Physician's Orders for Scope of Treatment (POST) (a physician's order which indicates end of life care preferences) for 1 (#46) of 24 sampled residents for POST forms. The findings include: Review of the medical record showed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Peripheral Venous Insufficiency, Acute Kidney Failure, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the POST form for Resident #46 dated 9/12/2019 showed no physician signature. Review of the Physician's Recapitulation Orders dated 1/2020 showed the resident had a Do Not Resuscitate (DNR) status. During an interview on 1/23/2020 at 8:30 AM, the Director of Nursing confirmed the POST dated 9/12/2019 had not been signed by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to follow contact isolation precautions for 1 resident (#60) of 4 residents observed for contact isolation. The findings include: Review of the facility's policy titled, Isolation Policy, revised 4/5/2016, showed .Contact Precautions .Personal Protective Equipment .Wear gloves and gown when entering the room .a mini-stop sign will be placed outside the door . Resident #60 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Type 2 Diabetes, and Major Depressive Disorder. Review of a Physician's Telephone Order dated 1/14/2020 showed contact precaution for Urinary Tract Infection (UTI) Multidrug Resistant Organism (MDRO). Observation at Resident #60's room on 1/21/2020 at 11:00 AM, showed a large metal box placed on the resident's entrance door with no signage on the door. During an interview on 1/21/2020 at 11:20 AM, Licensed Practical Nurse (LPN) #1 stated the resident was on contact isolation due to MDRO UTI. Observation on 1/21/2020 at 12:46 PM, showed LPN #1 entered the resident's room, donned gloves, and administered medication to Resident #60. Observation on 1/21/2020 at 12:48 PM, showed the Unit Secretary entered the resident's room without donning gloves or gown. During an interview on 1/21/2020 at 12:50 PM, the Unit Secretary stated she was not aware Resident #60 was on contact isolation .there is not a sign on the door . During an interview on 1/21/2020 at 12:55 PM, LPN #1 stated the staff had to don gloves prior to entering the resident's room and wear a gown if the staff came in contact with bodily fluids or .up close care . LPN #1 confirmed there was no contact isolation sign on Resident #60's door. Observation of the resident on 1/23/2020 at 9:40 AM, showed the resident sitting in a chair in her room with Certified Nursing Assistant (CNA) #1 present. Continued observation showed the staff member was not wearing a gown or gloves in the resident's room. During an interview on 1/23/2020 at 9:45 AM, with CNA #1 stated she had not applied gloves or gown prior to entering Resident #60's room, I know I should wear gloves but I was never told to wear a gown. During an interview on 1/23/2020 at 8:26 AM, the Director of Nursing confirmed the facility failed have contact isolation precautions in place for Resident #60 and failed to follow their facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview the facility failed to attempt a Gradual Dose Reduction (GDR) of psychotropic medications for 1 resident (#14), and failed to provide a rationale for the continued use of an as needed (PRN) antianxiety and antipsychotic medication beyond 14 days for 1 resident (#40) of 5 residents reviewed for unnecessary medications. The findings include: Review of the medical record showed Resident #14 was admitted to the facility on [DATE], with diagnoses including Anxiety, Psychosis, Dementia and Major Depressive Disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 received antidepressant medications on all 7 days of the assessment look back period. Review of the Physician Recapitulation Orders for 1/1/2020 - 1/31/2020, showed Mirtazapine (antidepressant) 30 milligrams (mg) by mouth twice daily with an order date of 2/7/2018 and Sertraline (antidepressant) 50 mg 1and ½ tablets by mouth daily with an order date of 2/11/2019. Observation of the resident on 1/22/2020 at 10:16 AM, Resident #14 was seated outside of the beauty shop interacting with staff with no behaviors. During an interview on 1/23/2020 at 11:50 AM, the Director of Nursing (DON) confirmed that a GDR had not been attempted for Sertraline or Mirtazapine since the medications were first prescribed. Review of the medical record showed Resident #40 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder, and Other Dissociative and Conversion Disorders. Review of the Quarterly MDS dated [DATE] showed Resident #40 scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. The resident had no moods or behaviors and the resident received antianxiety, antidepressant and opioid medications. Review of the hospital Discharge Medication List dated 1/1/2020 showed Alprazolam 0.5 mg (antianxiety medication) every 8 hours PRN with no stop date and Olanzapine disintegrating tablet (antipsychotic medication) 5 mg every 6 hours PRN with no stop date. Review of the Medication Administration Record (MAR) dated 1/1/2020 through 1/23/2020 showed the PRN Olanzapine continued beyond 14 days without a stop date. The MAR showed Resident #40 was administered the PRN Alprazolam 0.5 mg daily from 1/2/2020 through 1/22/2020 a total of 8 days beyond the 14 day time frame. Observation of Resident #40 on 1/22/2020 at 3:25 PM and 1/23/2020 at 8:40 AM revealed the resident lying in his bed with no behaviors exhibited. During an interview on 1/23/2020 at 11:50 AM, the DON confirmed the PRN Olanzapine and the PRN Alprazolam did not have a discontinue date or end date ordered and the medications continued beyond the 14 day time frame.