**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise the Care Plan for 2 of 6 (Residents #2 and #3) residents reviewed. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 3/2/2022, revealed, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team .The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], discharged home on 7/26/2023, and readmitted on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare Following Surgical Amputation, Acute Osteomyelitis Left Ankle and Foot, Cellulitis of Left Lower Limb, Type 2 Diabetes Mellitus with Hyperglycemia, and Peripheral Vascular Disease. Review of the Order Summary Report for Resident #2 revealed orders for, .8/17/2023 Clean 5th left toe on the left foot with NS [Normal Saline] apply black foam on wound, secure with [named transparent dressing], machine at 120 mmg [milligrams of mercury] change M [Monday]/W [Wednesday]/F [Friday] and PRN [as needed] .8/25/2023 Continue [named negative pressure device] left foot .8/31/2023 Clean right surgical wound with NS apply [named Hydrocolloid wound filler paste] wrap with [named gauze bandage] every day shift . (This order was written in error as the right surgical wound, when in fact it was the left foot surgical wound. The Director of Nursing (DON) and the Treatment Nurse wrote an attestation to confirm the order was written as the right foot, but was in fact pertaining to the left foot, and the treatments were performed on the left foot.) Review of the admission Minimum Data Set (MDS) assessment for Resident #2 dated 8/19/2023 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Continued review revealed an infection of the foot and application of dressings to feet. Review of the undated Care Plan for Resident #2 revealed Focus/Assessments for, .Has break in skin integrity, BUE [Bilateral Upper Extremity] and BLE [Bilateral Lower Extremity] has several blisters that opened and are draining from cellulitis . Resident #2's Care Plan did not address the wound to his left foot post surgical amputation, nor the laceration with sutures to his right foot post fall, and did not include achievable goals or interventions. During an interview on 9/19/2023 at 3:18 PM, the DON stated, There should be a care plan entry when someone receives sutures from an injury. Typically, the nurses do not add to the care plans. The MDS person puts the care plan together. The Assistant Director of Nursing (ADON) or the MDS nurse will update the care plan as needed. [Named Resident #2]'s care plan should have been updated to include the laceration with sutures. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Surgical Aftercare Following Surgery on the Skin and Subcutaneous Tissue, and Acute Osteomyelitis of Left Foot and Ankle. Review of the Order Summary Report for Resident #3 revealed an order dated 8/25/2023, R [right] ankle, Non removable drsg [dressing], Monitor daily for integrity and s/sx [signs/symptoms] of infection. Review of the admission MDS assessment for Resident #3 dated 8/28/2023 revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed Resident #3 had a surgical wound and received surgical wound care. Review of Resident #3's undated Care Plan revealed the care plan did not include an assessment related to a surgical wound, achievable goals, or appropriate interventions. During an interview on 9/19/2023 at 4:08 PM, the MDS Coordinator reviewed Resident #3's Care Plan. The MDS Coordinator confirmed Resident #3's care plan did not address the surgical wound, have achievable goals, or appropriate interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain physician's orders for 1 of 6 (Resident #2) residents reviewed. The findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], discharged home on 7/26/2023, and readmitted on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare Following Surgical Amputation, Acute Osteomyelitis Left Ankle and Foot, Cellulitis of Left Lower Limb, Type 2 Diabetes Mellitus with Hyperglycemia, and Peripheral Vascular Disease. Review of the notes from the Infectious Disease physician's office visit for Resident #2 dated 6/22/2023, revealed, .Chronic ulcer of toes of left foot .should perform 3/x [times] week dressing changes and apply [named Hydrophobic microbe binding wound contact layer] to the would bed ulcer . Review of the Wound Observation Tools for Resident #2 revealed there were no wound assessments documented until 7/18/2023, which stated, .left foot .First observation .Granulation tissue present .Drainage: Serosanguinous [clear liquid mixed with blood] .Length (cm) [centimeters] 1.0 .Width (cm) 1.0 .Depth (cm) 0.1 .Resident's wound bed with granular tissue wife reported that he sees a podiatrist he has PVD [Peripheral Vascular Disease] scab removed dressed, NP [Nurse Practitioner] and family aware .Treatment: [named Hydrophobic microbe binding wound contact layer] . Continued review dated 7/25/2023, revealed, .left foot .Improving .Granulation tissue present .Drainage: Serosanguinous [clear liquid mixed with blood] .Length (cm) 1.0 .Width (cm) 1.0 .Depth (cm) 0.1 .Resident's wound bed with granular NP and family aware .Treatment: [named Hydrophobic microbe binding wound contact layer] . Review of the Order Summary Report for Resident #2 revealed orders for, .7/20/2023 Clean left foot with NS [Normal Saline] apply [named Hydrophobic microbe binding wound contact layer] every day shift every 3 days for PVD . Review of the hospital emergency room (ER) notes for Resident #2 dated 8/24/2023 revealed, .a fall and right foot injury .has a laceration in the webspace between the 4th and 5th toes .LLE [Left Lower Extremity] w [with] .bandage taken down and wound healing well w/o [without] infection/drainage/erythema [redness] . Radiology report of the Right foot revealed, .there has been a partial resection of the distal [end of] phalanx of the great toe .Severe arterial vascular calcification present .Acute nondisplaced fracture present involving the proximal phalanx [lower end] of the fifth digit/little toe . Continued review revealed, .Disposition Decision .Discharge to home[nursing home.] Additional Instructions: Your labs and imaging were unremarkable today except for a fracture of your pinky toe. You had sutures to repair your laceration. Please continue antibiotics at . nursing home as previously prescribed and follow-up with your foot surgeon for suture removal in 7-10 days . Review of the Order Summary Report for Resident #2 revealed orders for, .8/31/2023 Clean right surgical wound with NS [Normal Saline] apply [named Hydrophobic microbe binding wound contact layer] wrap with [named gauze bandage] every day shift . (This order was actually written for the left foot amputation performed on 8/2/2023 and was mistakenly entered as the right foot. The Director Of Nursing (DON) and Treatment Nurse both wrote an attestation indicating the order was entered into the system wrong, but the treatments were conducted correctly on the left foot.) Review of the Progress Note for Resident #2 dated 9/5/2023, written by the NP, revealed, . dressing to R [right] foot for protection of sutures-after fall/laceration . Review of the Progress Note for Resident #2 dated 9/11/2023, written by the NP [Nurse Practitioner], revealed, .Patient also with L [left] foot wound and sutures to R foot. Both feet covered with dressings on assessment today-dry and intact . During an interview on 9/19/2023 at 1:19 PM, the Treatment nurse stated when Resident #2 was admitted to the facility in May 2023, he did not have any open areas to his skin. The treatment nurse stated there was a note in Resident #2's chart from the facility's doctor stating the skin on his feet was intact. The Treatment Nurse stated Resident #2 came from a doctor's appointment on 6/22/2023 and had orders for a treatment to his foot. The Treatment Nurse stated the doctor had debrided (removed) the scab that had been on his foot, and after the debridement (removal), there was an open wound. She stated she was not made aware of the treatment order, did not know there was a wound, and therefore did not monitor the wound on a weekly basis. The Treatment nurse stated the Charge nurse who had Resident #2 that day, should have obtained the order for the treatment. During an interview on 9/19/2023 at 2:55 PM, the DON stated Resident #2 had a fall in his room on 8/24/2023, which resulted in a fracture to his toe on his right foot, and a laceration that required sutures. The DON confirmed there were no orders obtained related to monitoring the laceration and no treatment orders. The DON stated, The only orders I see in the chart are to remove the sutures in 8-10 days. There is no order for wound care or observing the wound. I would have expected an order written to change the dressing and to monitor the wound for infection. During an interview on 9/19/2023 at 3:18 PM, the DON confirmed the orders written by the Infectious Disease doctor on 6/22/2023 were not carried over. The DON confirmed, I would expect the nurse to enter the new order. During an interview on 9/20/2023 at 11:29 AM, The NP stated, .resident had an injury to his right foot when he got up and tried to walk . When asked if the NP would have expected an order to be written for monitoring the wound with sutures for infection, she replied, yes. During an interview on 9/20/2023 at 12:00 , the DON reviewed Resident #2's physician orders. The DON confirmed there was no order for a treatment to Resident #2's left foot on 6/13/2023. The DON reviewed the Infectious Disease doctor's progress note for Resident #2 dated 6/13/2023 which stated the dressing to the resident's left foot was clean, dry, and intact. The DON stated the Infectious Disease doctor's office could have applied a dressing over the left foot and did not write an order for it. The DON stated when the resident returned to the facility after the MD appointment, the nurse should have noted the dressing and investigated why the dressing was there and should have notified the Treatment Nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report allegations of abuse for 2 of 2 sampled residents (Resident #1 and Resident #5) reviewed. The findings include: Review of the facility policy titled, Area of Focus: Abuse & Neglect, reviewed 11/21/2022, revealed, .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .In response to allegations of abuse .the facility must .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegations is made .not later than 24 hours if the events that cause the allegation do not involve abuse .In response to allegations of abuse .the facility must .Have evidence that all alleged violations are thoroughly investigated .Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Age-Related Osteoporosis with Current Pathological Fracture, Right Humerus, Age-Related Osteoporosis with Current Pathological Fracture, Right Forearm, and Generalized Weakness. During an interview on 4/3/2023 at 9:58 AM Ombudsman #1 stated, I spoke with [Resident #1] and her family about the allegations of abuse. [Resident #1] told me [Certified Nursing Assistant (CNA) #2] had been too rough with her and she was terrified of [CNA #2]. [Resident #1] said [CNA #2] was mean to her the first night she stayed in the facility [Facility #1]. [Family Member #5] said the DON [Director of Nursing] said she would investigate [CNA #2] and she [CNA #2] would not be allowed back in [Resident #1]'s room. I talked to the DON and she was aware of the allegations made by [Resident #2] and she had taken care of the situation and [CNA #2] would not be caring for [Resident #1] anymore. During a telephone interview on 4/3/2023 at 11:49 AM, Family Member #1 stated, [Resident #1] was terrified the morning of 2/25/2023 and tearful when she described how [CNA #2] had treated her during her first night in the facility. I came to the facility on 2/27/2023 and met with the DON, We discussed the allegations of abuse made by [Resident #2] and she [DON] said she would report the allegations to the State and investigate thoroughly. The DON said in the meantime she would move [Resident #1] and [CNA #2] would not be taking care of [Resident #1]. During an interview on 4/4/2023 at 1:50 PM, Resident #1 stated, [CNA #2] had been really rough when she turned me on my side to change me. I told her she was hurting me and she still pushed me around and was really rough turning me. She [CNA #2] seemed mad at me for needing help. She told me I called too much. I have been okay since [family member #5] has been able to stay with me and the other techs [CNAs] are pretty good to take care of me. Continued interview Resident #1 described CNA #2 as the tech that was too rough with her and scared her on 2/24/2023. During an interview on 4/4/2023 at 2:00 PM, Family Member #5 stated, I came to the facility on 2/25/2023 and [Resident #1] told me she didn't think she could stay in the facility after the bad treatment from a CNA she received from [CNA #2] during the night. I told the nurse about what [Resident #1] said about the CNA. The nurse said she would report it to the DON. I stayed with her that night [2/25/2023] and [Resident #1] pointed the CNA out to me when she came in the room. The CNA was an older woman with long gray hair, her name was [CNA #2]. On Monday, 2/27/2023 we [Family Member #1 and Family Member #5] met with the DON in her office. She [DON] told us [CNA #2] would not be taking care of [Resident #1] anymore because we were moving to a private room that wasn't on [CNA #2]'s assignment. She [DON] told us she was going to investigate the incident and turn it in to the State. After she said that, she called the Social worker and the Administrator into the office and told them about the incident. The Social worker said she would make arrangements to move [Resident #1] right away. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Unspecified Intracranial Injury with Loss of Consciousness Status Unknown Subsequent Encounter, Unspecified Fracture of Left Acetabulum Subsequent Encounter for Fracture with Routine Healing, Pain in Left Hip, and Unspecified Injury of Bladder Subsequent Encounter. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. During an interview on 4/3/2023 at 3:45 PM, Family Member #3 stated, I was on the phone with my dad [Resident #5], and a staff member come in the room and started yelling at him regarding pressing his call light too many times. Family Member #3 stated that the Resident #5 started crying and was confused on why he was being yelled at, so she hung up and called the facility immediately to report what had just happened. Family Member #3 stated that she spoke with the nurse on duty and was told that the tech would be reassigned and would not provide care for [Resident #5] anymore. During an interview on 4/4/2023 at 3:30 PM, LPN #1 stated, I wasn't working down on that hall, but I went down there when I got the call. [CNA #1] was working, and she has a tendency of speaking loudly. I [LPN #1] reported the incident to the DON, but I don't remember an investigation being done. The DON and I [LPN #1] met with the family the following week and informed the family that [CNA #1] would no longer be providing care to [Resident #5]. During an interview on 4/5/2023 at 9:35 AM, Resident #5 stated that a CNA came into his room and yelled at him regarding pressing his call light too many times. Resident #5 stated the CNA spoke very loudly with him. Resident #5 stated that his daughter was on the phone with him and called the facility to report what happened immediately. Resident #5 stated, After the incident, I felt uncomfortable pressing call light when I needed help. During an interview on 4/4/2023 at 4:11 PM, the DON confirmed the definitions of abuse according to the facility policy. She stated verbal abuse included talking mean to a resident and mistreatment of a resident. She stated, If a resident alleges abuse by a staff member, the staff member would be suspended pending an investigation. The DON confirmed she did not report or investigate an allegation of abuse made by Resident #1 and Resident #5. She stated she remembered a meeting in her office between Resident #1's family members and administration. She was unable to recall why Resident #1's family members did not want CNA #2 to take care of Resident #1. The DON also stated that she didn't remember meeting with Resident #5 or Resident #5's family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to investigate allegations of abuse for 2 of 2 sampled residents (Resident #1 and Resident #5) reviewed. The findings include: Review of the facility policy titled, Area of Focus: Abuse & Neglect, reviewed 11/21/2022, revealed, .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .In response to allegations of abuse .the facility must .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegations is made .not later than 24 hours if the events that cause the allegation do not involve abuse .In response to allegations of abuse .the facility must .Have evidence that all alleged violations are thoroughly investigated .Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Age-Related Osteoporosis with Current Pathological Fracture, Right Humerus, Age-Related Osteoporosis with Current Pathological Fracture, Right Forearm, and Generalized Weakness. During an interview on 4/3/2023 at 9:58 AM Ombudsman #1 stated, I spoke with [Resident #1] and her family about the allegations of abuse. [Resident #1] told me [Certified Nursing Assistant (CNA) #2] had been too rough with her and she was terrified of [CNA #2]. [Resident #1] said [CNA #2] was mean to her the first night she stayed in the facility [Facility #1]. [Family Member #5] said the DON [Director of Nursing] said she would investigate [CNA #2] and she [CNA #2] would not be allowed back in [Resident #1]'s room. I talked to the DON and she was aware of the allegations made by [Resident #2] and she had taken care of the situation and [CNA #2] would not be caring for [Resident #1] anymore. During a telephone interview on 4/3/2023 at 11:49 AM, Family Member #1 stated, [Resident #1] was terrified the morning of 2/25/2023 and tearful when she described how [CNA #2] had treated her during her first night in the facility. I came to the facility on 2/27/2023 and met with the DON, We discussed the allegations of abuse made by [Resident #2] and she [DON] said she would report the allegations to the State and investigate thoroughly. The DON said in the meantime she would move [Resident #1] and [CNA #2] would not be taking care of [Resident #1]. During an interview on 4/4/2023 at 1:50 PM, Resident #1 stated, [CNA #2] had been really rough when she turned me on my side to change me. I told her she was hurting me and she still pushed me around and was really rough turning me. She [CNA #2] seemed mad at me for needing help. She told me I called too much. I have been okay since [family member #5] has been able to stay with me and the other techs [CNAs] are pretty good to take care of me. Continued interview Resident #1 described CNA #2 as the tech that was too rough with her and scared her on 2/24/2023. During an interview on 4/4/2023 at 2:00 PM, Family Member #5 stated, I came to the facility on 2/25/2023 and [Resident #1] told me she didn't think she could stay in the facility after the bad treatment from a CNA she received from [CNA #2] during the night. I told the nurse about what [Resident #1] said about the CNA. The nurse said she would report it to the DON. I stayed with her that night [2/25/2023] and [Resident #1] pointed the CNA out to me when she came in the room. The CNA was an older woman with long gray hair, her name was [CNA #2]. On Monday, 2/27/2023 we [Family Member #1 and Family Member #5] met with the DON in her office. She [DON] told us [CNA #2] would not be taking care of [Resident #1] anymore because we were moving to a private room that wasn't on [CNA #2]'s assignment. She [DON] told us she was going to investigate the incident and turn it in to the State. After she said that, she called the Social worker and the Administrator into the office and told them about the incident. The Social worker said she would make arrangements to move [Resident #1] right away. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Unspecified Intracranial Injury with Loss of Consciousness Status Unknown Subsequent Encounter, Unspecified Fracture of Left Acetabulum Subsequent Encounter for Fracture with Routine Healing, Pain in Left Hip, and Unspecified Injury of Bladder Subsequent Encounter. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. During an interview on 4/3/2023 at 3:45 PM, Family Member #3 stated, I was on the phone with my dad [Resident #5], and a staff member come in the room and started yelling at him regarding pressing his call light too many times. Family Member #3 stated that the Resident #5 started crying and was confused on why he was being yelled at, so she hung up and called the facility immediately to report what had just happened. Family Member #3 stated that she spoke with the nurse on duty and was told that the tech would be reassigned and would not provide care for [Resident #5] anymore. During an interview on 4/4/2023 at 3:30 PM, LPN #1 stated, I wasn't working down on that hall, but I went down there when I got the call. [CNA #1] was working, and she has a tendency of speaking loudly. I [LPN #1] reported the incident to the DON, but I don't remember an investigation being done. The DON and I [LPN #1] met with the family the following week and informed the family that [CNA #1] would no longer be providing care to [Resident #5]. During an interview on 4/5/2023 at 9:35 AM, Resident #5 stated that a CNA came into his room and yelled at him regarding pressing his call light too many times. Resident #5 stated the CNA spoke very loudly with him. Resident #5 stated that his daughter was on the phone with him and called the facility to report what happened immediately. Resident #5 stated, After the incident, I felt uncomfortable pressing call light when I needed help. During an interview on 4/4/2023 at 4:11 PM, the DON confirmed the definitions of abuse according to the facility policy. She stated verbal abuse included talking mean to a resident and mistreatment of a resident. She stated, If a resident alleges abuse by a staff member, the staff member would be suspended pending an investigation. The DON confirmed she did not report or investigate an allegation of abuse made by Resident #1 and Resident #5. She stated she remembered a meeting in her office between Resident #1's family members and administration. She was unable to recall why Resident #1's family members did not want CNA #2 to take care of Resident #1. The DON also stated that she didn't remember meeting with Resident #5 or Resident #5's family.

**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 ensure dignity for 1 of 5 sampled residents (Resident #30) who required an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident Rights, dated 5/6/2021, revealed, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Review of the facility's policy titled, Indwelling Urinary Catheter (Foley) Management, dated 8/22/2022, revealed, .The facility will ensure that residents admitted with urinary catheter, .the facility must ensure that residents receive treatment and care in accordance with professional standards . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Sacral Region Stage 4 and Infection and Inflammatory Reaction due to Indwelling Urethral Catheter. Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #30 had an indwelling catheter. Observation in Resident #30's room on 9/12/2022 at 12:30 PM, revealed Resident #30's catheter bag was on the left side of the bed without a privacy cover. Observation in Resident #30's room on 9/13/2022 at 12:30 PM, revealed Resident's #30 catheter bag was on the right side of the bed without a privacy cover. During an interview on 9/13/2022 at 9:41 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #30's catheter bag was not covered with a privacy cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 2 of 5 sampled residents (Resident #16 And Resident #82) reviewed. The findings include: Review of the facility's policy titled, Pre-admission SCREENING and RESIDENT REVIEW [PASARR], dated 8/7/2021 revealed, .[PASARR] is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care .the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder [MD] or intellectual disability [ID] has a significant change in their physical or mental condition . Review of the medical record revealed Resident #16 was admitted on [DATE] with diagnoses which included Anxiety and Major Depressive Disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #16 received an antipsychotic over the last 7 days. Review of Resident #16's current Order Summary Report revealed an order for Risperidone Tablet 1 milligram (mg) give 1 tablet by mouth at bedtime for Bipolar Disorder and Xanax Tablet 0.5 mg give 1 tablet by mouth as needed for Anxiety. Review of Resident #16's Psychiatric Evaluation dated 4/29/2022, 6/3/2022, 6/17/2022, 6/28/2022, and 7/8/2022 revealed a diagnosis of Generalized Anxiety Disorder and Bipolar Disorder. Review of Resident #16's PASARR revealed, .Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past .Depression . Review of the medical record revealed Resident #82 was admitted on [DATE] with diagnoses which included Depression, Atrial Fibrillation, and Cerebral Infarction. Review of the admission MDS dated [DATE] revealed Resident #82 had a BIMS score of 13 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #82 received an antipsychotic and antidepressant over the last 7 days. Review of Resident #82's current Order Summary Report revealed an order for Bupropion Hydrochloride (HCL) Extended Release 150 mg give 1 tablet by mouth one time a day for Depression and Seroquel tablet 50 mg give 1 tablet by mouth at bedtime for Psychosis. Review of Resident #82's PASARR revealed .Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past .No mental health diagnosis is known or suspected .Has the individual been prescribed psychoactive [mental Health] medications now or within the past 6 months .yes .Aricept . During an interview on 9/14/2022 at 12:10 PM, Social Service Director confirmed Resident #82's PASAAR was not correct and should be updated. During an interview on 9/14/2022 at 2:45 PM, Executive Director confirmed Resident #16's PASARR was not correct and should be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, documentation review, medical record review, observations, and interviews, the facility failed to provide Activities of Daily Living (ADL) care for 1 of 24 sampled residents (Resident #30) reviewed. The findings include: Review of facility's policy titled, Activities of Daily Living (ADLs), dated 8/22/2022, revealed, . Assist resident with bed/wheelchair repositioning as necessary to promote good body alignment and prevent skin breakdown . Review of the undated facility documentation titled, Area of Focus: Basic Skin Management, revealed, .All residents have preventive measures in place that include pressure redistribution mattresses on all beds, wheelchair cushion, heel boots or suspension if needed, frequent repositioning per CNA [Certified Nursing Assistant] and ADL care, incontinent care provided with skin cleansers/wipes and barrier cream application if needed . Review of facility's policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated 4/19/2022, revealed, .Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries .diabetes mellitus .reposition at least every 2 .as consistent with overall patient goal and medical condition . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Sacral Region Stage 4, Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Type 2 Diabetes Mellitus with Hyperglycemia, and Unspecified Dementia without Behavioral Disturbance. Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #30 required total assistance with two person physical assist with bed mobility. Continued review revealed the resident had one unhealed Stage 3 pressure ulcer. Review of Resident #30's Wound Center documentation dated 8/19/2022, revealed, .Off-loading .alternate from side to side every hour. Do not allow patient to lay flat on back . Observation on 9/13/2022 at 9:33 AM, 11:10 AM, 1:24 PM, and 2:20 PM, revealed Resident #30 was lying in the same position. Resident #30 was lying partially on her right side, wedge to left side of shoulder with head of bed elevated. During an interview on 9/12/2022 at 12:30 PM, Resident #30's family member stated, I am concerned about her bed sore. I come for 2 meals daily and she is not being turned every 2 hours. I was here most of the day yesterday and she was never turned while I was here. During an interview on 9/13/2022 at 1:45 PM, CNA #5 confirmed she was assigned to provide care for Resident #30. CNA #5 confirmed she had not turned and repositioned Resident #30 since she clocked in at 7:00 AM. During an interview in Resident #30's room on 9/13/2022 at 2:10 PM, Resident's family member confirmed she had not been turned or repositioned since he arrived at 12:00 PM. During an interview on 9/13/2022 at 2:30 PM, the Wound Care Nurse stated she provided wound care at 7:30 AM. She confirmed Resident #30 should be turned and repositioned every 2 hours. During an interview on 9/13/2022 at 2:45 PM, the Director of Nursing (DON) confirmed a dependent resident should be turned every two hours and as the resident desires.

**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 follow physician orders for 1 of 24 sampled residents (Resident #589) reviewed. The findings include: Review of the facility's policy titled, Physician Orders, revised 3/17/2022, revealed .A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable and federal guideline .Physician orders include the following .Medication and Treatment . Review of the medical record revealed Resident #589 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Respiratory Failure and Obstructive Sleep Apnea. Review of the current Order Summary Report for Resident #589 revealed, .9/11/2022 Oxygen at 2 liters/minute continuously per nasal cannula. Document every shift for chronic respiratory failure . Observations in Resident #589's room on 9/13/2022 at 8:30 AM and 9:52 AM, revealed the oxygen flow was set to deliver 3 liters per minute. During an interview on 9/13/2022 at 9:52 AM, Licensed Practical Nurse (LPN) #2 confirmed resident #589's oxygen was set to deliver 3 liters per minute, and should have been set to deliver 2 liters per minute. During an interview on 9/13/2022 at 10:58 AM, Director of Nursing (DON) confirmed physician orders related to oxygen liter flow should be followed as written. During an interview on 9/13/2022 at 1:40 PM, Family Member #1 confirmed he has never changed the oxygen settings.

**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 label oxygen tubing when changed for 1 of 10 sampled residents (Resident #589) reviewed. The findings include: Review of the facility's policy titled, Oxygen Administration/Safety/Storage/Maintenance, revised 8/2/2021, revealed, .Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when setup or changed . Review of the medical record revealed Resident #589 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Respiratory Failure and Obstructive Sleep Apnea. Review of the current Order Summary Report for Resident #589 revealed an order to change oxygen tubing every Sunday night. Observations in Resident #589's room on 9/13/2022 at 8:30 AM, revealed the oxygen cannula tubing was not labeled or dated. Observation and interview in Resident #589's room on 9/13/2022 at 9:52 AM, Licensed Practical Nurse (LPN) #2 confirmed resident #589's oxygen tubing was not labeled or dated. During an interview on 9/13/2022 at 10:58 AM, Director of Nursing (DON) confirmed oxygen tubing should be changed weekly on Sunday night and should be labeled and dated.

Based on facility documentation review and interview the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for the 18 months reviewed. The findings include: Review of the daily staffing sheets from 3/1/2021-9/13/2022, revealed the following days 6/18/2021, 7/12/2021, 7/16/2021, 7/17/2021, 7/26/2021, 7/31/2021, 8/1/2021, 7/30/2021, 8/5/2021, 8/9/2021, 8/10/2021, 8/17/2021, 8/18/2021, 8/19/2021, 8/28/2021, 8/29/2021, 10/1/2021, 10/8/2021, 10/9/2021, 10/10/2021, 10/18/2021, 10/19/2021, 10/23/2021, 10/24/2021, 11/19/2021, 12/31/2021, 6/18/2022, and 7/2/2022 without 8 consecutive hours of RN coverage. During an interview on 9/13/2022 at 9:24 AM, Executive Director confirmed facility should have 8 hours of RN coverage.

Based on facility policy review, facility documentation review, observations, and interviews, the facility failed to have the Daily Nurse Staffing form posted for 1 of 3 days of survey. The findings include: Review of the facility policy titled, Staffing, dated 7/27/2022, revealed, .The facility posts daily staffing information in a clear readable format in a prominent place that is easily accessible to residents and visitors at any given time . Observation on 9/12/2022 at 1:00 PM and 4:30 PM, there was no Daily Nurse Staffing form posted. During an interview on 9/12/2022 at 4:54 PM, Staffing Coordinator and Registered Nurse #1 confirmed that Daily Nurse Staffing form was not posted.

**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 medication was stored properly for 1 of 24 sampled residents (Resident #43) reviewed. The findings include: Review of the facility's policy titled, Administration of Medications, revised 5/6/2022, revealed, .facility will ensure medications are administered safely and appropriately per physician order . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Age Related Osteoporosis, Unspecified Dementia, and Muscle Weakness. Continued review revealed there was no assessment completed for Self Administration of Medication. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan for Resident #43 revealed, .resident has a swallowing problem r/t [related to] Complaints of difficulty or pain with swallowing .resident is at risk for aspiration . Review of the Order Summary Report for Resident #43 revealed the resident did not have an order to self administer medications and no order for the resident's daughter to administer medications. Observation and interview in Resident #43's on 9/12/2022 at 1:50 PM, revealed a medicine cup containing medication, sitting on the table in front of the resident. Resident #43 stated the nurse leaves the vitamins in the room for her daughter to administer to her. Continued interview family member #2 stated the vitamins are difficult for Resident #43 to swallow. She stated the nurses always leaves the vitamins for her to give throughout the day. Observation and interview in Resident #43's room on 9/12/2022 at 1:58 PM, revealed Unit Manager #1 confirmed the medicine cup containing medication had been left in the resident's room. During an interview on 9/12/2022 at 3:40 PM, the Director of Nursing (DON) stated she had reviewed Resident #43's medical record and confirmed there was not an order for the Resident or family member #2 to administer medication.

Based on facility policy review, observations, and interview, the facility failed to dispose of expired food items in the nourishment room refrigerators. The findings include: Review of the facility's policy titled, Safe Food Handling, revised 2/2/2022, revealed, .All food purchased, stored and distributed is handled with accepted food-handling practices .Snacks and other food items sent from the foodservice department will be handled safely in regard to temperature, labeling and storage . Review of the facility's staff information poster regarding Use By Date, revealed, .Thickened Liquids Use By Date 7 days .Once the supplement/thickened liquid reaches it's use by date, throw it in the trash can . Observation and interview in the 100 Hall nourishment room on 9/13/2022 at 11:20 AM, there was an opened carton of thickened apple juice with an opened date of 6/3/2022. The Registered Dietician (RD) confirmed the opened date of the apple juice was 6/3/2022. She confirmed that the apple juice was expired. Observation and interview in the 200 Hall nourishment room on 9/13/2022 at 11:25 AM, there was an opened carton of thickened sweet tea with an opened date of 9/5/2022. The RD confirmed the thickened sweet tea was expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to follow infection control guidelines to minimize the risk of potential exposure to the Coronavirus (COVID-19) for 75 residents. The facility also failed to properly dispose of a urinary catheter drainage system in a manner to prevent transmission of potential infectious agents for 1 of 5 sampled residents (Resident #54) requiring a urinary catheter. The findings include: Review of the facility's policy titled, Coronavirus (COVID 19) (SARS-CoV-2) revised 9/6/2022, revealed, .to minimize the risk of potential exposure to the Coronavirus .All recommended COVID-19 PPE [Personal Protective Equipment] should be worn during care of residents under quarantine, which includes use of an N95 or higher-level respirator . Observation of #206's bathroom and interview on 9/12/2022 at 12:15 PM, Licensed Practical Nurse (LPN) #3 was wearing a KN95 (type of face covering made in China, not approved by NIOSH [National Institute of Occupational Safety and Health]) mask and goggles while in patient care areas. She stated the KN95 mask was appropriate PPE. Observation and interview on 100 Hall on 9/12/2022 at 12:20 PM, revealed Certified Nursing Assistant (CNA) #4 entered a room with Transmission Based Precautions (TBP). She donned goggles, mask, gown and gloves before entering the room. During an interview at 12:23 PM, CNA #4 stated she donned a KN95 mask when she entered the TBP room. She confirmed the TBP signage required the use of an N95 mask. During an interview on 9/12/2022 at 12:27 PM, Registered Nurse (RN)/Staffing Development Coordinator stated staff was required to wear an N95 mask and face covering or goggles in the facility when in patient care areas. Observation of 100 Hall on 9/12/2022 at 1:33 PM, revealed Physical Therapist (PT) #1 wearing a KN95 mask while providing care for a resident ambulating in the hall. During an interview on 9/12/2022 at 1:33 PM, PT #1 stated she understood the KN95 mask was all that she needed and confirmed she was wearing a KN95 mask. Review of the facility policy titled, Condom Catheter Application, reviewed 8/22/2022, revealed, .facility will provide Condom Catheter Application in accordance with professional standards of practice .facility will utilize the [Named] procedure . Review of facility documentation titled, External Urine Collection Device Use, Male, revised 11/19/2021, revealed, .Removing the device .Discard the device and drainage bag in an appropriate receptacle . Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Acute Cystitis, and Retention of Urine. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Continued review revealed the resident had an external catheter, and was always incontinent of urine. Review of the Comprehensive Care Plan for Resident #54 revealed, .Potential for complications related to incontinence .orders for condom catheter . Review of the current Order Summary Report for Resident #54 revealed, .8/5/2022 .Ok to use Condom Catheter every shift for Incontinence . Review of the Medication Administration Record (MAR) for Resident #54 dated 9/1/2022-9/30/2022, revealed documentation for use of Condom Catheter daily. Observation in Resident #54's bathroom on 9/12/2022 at 12:08 PM, revealed a urinary drainage bag and tubing laying on top of clothing in a wheelchair. The tubing and bag had white cloudy debris inside. Observation and interview in Resident #54's bathroom on 9/12/2022 at 12:15 PM, Licensed Practical Nurse (LPN) #3 stated the urinary drainage bag and tubing looked dirty and confirmed the used urinary drainage bag was in the wheelchair. During an interview on 9/13/2022 at 4:45 PM, the Director of Nursing (DON) stated she expected staff to follow Professional Standards of Practice for Infection Control when caring for residents. She confirmed storing a used urinary drainage bag in a chair was not in accordance with Professional Standards of Practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain wound care orders upon admission for 1 Resident (#17) of 6 Residents reviewed. The findings include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Infection and Inflammatory Reaction due to Internal Left Prosthesis, Presence of Left Artificial Hip Joint, and Muscle Weakness. Medical record review of the Physician Orders dated 3/9/18 revealed .Admit to [facility] for skilled services under the care of [Physician]: Generalized weakness r/t [related to] ORIF [open reduction and internal fixation] left hip . Further review of the orders revealed no wound care orders for Resident #17. Medical record review of the Hospital Discharge Summary dated 3/9/18 revealed .Aquacel dressing was to remain on and be changed per wound care instructions. She was to follow [up] with [Physician] in 10 days. All discharge instructions were reviewed. All questions answered and appropriate prescriptions provided. The patient was discharged to [facility]. Discharge packet was sent to the facility, report was called and all Physician Orders and medical instructions were communicated . Medical record review of the Progress Notes dated 3/9/18 revealed .surgical incision to left hip . by Licensed Practical Nurse (LPN #4) Interview with the Assistant Director Of Nursing (ADON) 5/22/18 at 2:43 PM in the charting room when asked Whose responsibility it was to obtain wound care orders? The ADON stated The Wound Care Nurse would follow up on orders and she would call the Surgeon. Somebody should have saw her within 24 hours either the NP [nurse practitioner] or the Doctor. Interview with the Unit Manager (UM #1) on 05/22/18 at 2:48 PM in the chart room when asked What did the wound look like on admission and were there orders? The UM #1 stated On admission it was closed, I am gonna say there were no treatment orders. Telephone interview with LPN #4 on 5/23/18 at 11:20 AM revealed Resident #17 came with orders, but when asked about specific orders for Resident #17's hip LPN #4 stated Not for the left leg [surgical site], nothing was done to it until somebody noticed she had drainage. I did not feel it was a problem until it was draining. Continued interview revealed the facility failed to obtain Wound Care Orders for immediate care for Resident #17.

**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 the standard of care for peripheral intravenous (IV) catheters for 1 Resident (#193) of 9 Residents reviewed; and failed to follow the standard of care for Peripherally Inserted Central Catheter (PICC) dressing changes for 1 Resident (#17) of 9 Residents reviewed with PICC's. The findings include: Review of facility policy Peripheral Catheter Insertion undated, revealed .IV sites will be changed every three (3) days or as otherwise ordered by the physician .Place a label on the dressing with insertion date, catheter type, and initials . Review of facility policy Central Vascular Access Device (CVAD) Dressing Change dated 5/1/16 revealed .Sterile dressing change using trasparent dressing is performed: At least weekly . Review of facility policy Central Vascular Access Device (CVAD) Dressing Change dated 5/1/16 revealed .Sterile dressing change using trasparent dressing is performed: At least weekly . Medical record review revealed Resident #193 was admitted to the facility on [DATE] with diagnoses including Left Femur Fracture, History of Falling, Encounter for Orthopedic Aftercare and Muscle Weakness. Medical record review revealed a Physician's Order dated 5/11/18 for Resident #193 to receive IV fluids. Observation on 5/21/18 at 3:50 PM in Resident #193's room revealed the resident had an IV access in the right outer wrist with a date on the dressing of 5/11/18. Observation and interview with Licensed Practical Nurse (LPN #3) on 5/21/18 at 3:56 PM in Resident #193's room confirmed the IV was dated as last changed on 5/11/18. Further interview confirmed the IV site was to be changed every 3 days and the facility had failed to provide the dressing change. Interview with the Assistant Director of Nursing on 5/22/18 at 1:40 PM at the 200 Nurse's Station confirmed the facility standard of care for peripheral IV's was to change the site every 3 days unless there was a specific order not to change the site. Further interview confirmed there was not a specific order for Resident #193 not to change the site. Continued interview confirmed the facility failed to follow the standard of care for peripheral IV's for Resident #193. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, Infection and Inflammatory Reaction due to Internal Left Prosthesis, Presence of Left Artificial Hip Joint, End Stage Renal Disease, Hypothyroidism, and Muscle Weakness. Observation on 5/22/18 at 8:09 AM in Resident #17's room revealed a PICC to the upper right arm with a dressing dated 4/30/18. Observation and interview, with LPN #4 on 5/22/18 at 8:21 AM on the 300 hallway revealed the dressing changes were scheduled on the Medication Administration Record (MAR) and were to be changed once a week by any shift. Interview with LPN #4 revealed It is usually changed during the day, but the resident has been away at times. Further interview revealed there was not a reminder for staff or set day for dressing changes. Interview with Unit Manager (UM #1) on 5/22/18 at 8:25 AM at the 300 Nurse's Station revealed the PICC line dressing changes were every Tuesday on the MAR. Continued interivew revealed It is on our MAR like every medication. The floor nurse does the sterile dressing. Continued interview with UM #1 confirmed the facility failed to change the PICC line dressing weekly for 3 weeks between 4/30/18 through 5/22/18 for Resident #17.