**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, State Operations Manual (SOM) review, Internet website LocalConditions.com review, medical record review, observations, and interviews, the facility failed to recognize a resident's individuality and ensure treatment with respect and dignity in a manner and an environment that promoted maintenance or enhancement of quality of life, for 1 of 7 residents (Resident #1) reviewed for Resident Rights. The failure to recognize a resident's individuality and ensure treatment with respect and dignity resulted in the facility's failure to protect and promote the rights of the resident. The findings included: Review of the facility's policy titled, Resident Rights, reviewed 3/22/2022 revealed, .The resident has the right to a dignified existence, self-determination .to be supported by the facility in the exercise of his or her rights .The resident has a right to be treated with respect and dignity . Review of the State Operations Manual (SOM) revealed, .483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81°F [Fahrenheit] . Review of the Internet website LocalConditions.com revealed the outside temperature on 7/21/2023 at 3:00 PM was 89 degrees F. On 8/14/2023 at 2:00 PM the temperature was 86 degrees F in the facility's local area. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lymphedema, Major Depressive Disorder, and Chronic Pain Syndrome. Review of the care plan for Resident #1 dated 6/16/2023 revealed, .Behavioral Symptoms .[Resident #1] is trying to keep her room temperature on 90 degrees .For her safety it should only be on 85 due to state guidelines [state guidelines indicate comfortable and safe temperatures 71 to 81 degrees Fahrenheit (F)] .goal .To maintain temp [temperature] in her room at an acceptable range .7/21/2023 .Her heater has a lock on it .reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Observations on 8/14/2023 at 2:11 PM, revealed Resident #1 in her room sitting in a chair next to the PTAC (Packaged Terminal Air Conditioner) Unit with a blanket around her upper body. The PTAC Unit control was padlocked. Resident #1 stated she was cold as usual and was not allowed to turn the heat up any higher. During an interview on 8/14/2023 at 2:11 PM, Resident #1 stated she didn't know what the temperature in the room was because the control panel was locked. Resident #1 stated she felt like her rights were violated by the facility when the PTAC Unit control pad was locked and she complained often about not being able to adjust the room temperature. Resident #1 stated the facility did not consider her rights or wishes when they placed the lock on the control panel. Resident #1 stated the Director of Nursing (DON) had told her the lock was being placed to prevent the roommate (Resident #7) from being too hot. Resident #1 stated she and Resident #7 both like the room extra warm. During an interview on 8/15/2023 at 9:55 AM, Licensed Practical Nurse (LPN) #1 stated the resident's PTAC unit control had a padlock on it to prevent Resident #1 from setting the heat on 90 degrees. LPN #1 stated, She has a roommate and state regulations say the temperature cannot be more than 85 degrees. LPN #1 confirmed Resident #7 (roommate) had not ever complained about the heat to her [LPN #1], rather the family had complained when they visited a few days ago. When asked what the temperature in the room was when the family complained, LPN #1 replied, I don't know really if it was checked. LPN #1 confirmed she was unable to tell this surveyor what temperature the unit was set on because the digital setting was not viewable with the controls padlocked. LPN #1 stated, Residents have the right to control the temperature in their room unless it makes it unsafe for them and their roommate. [Named Residents #1 and #7] always liked the room hot even though Resident #7 wore multiple layers of clothes. [Name Residents #1 and #7] had not shown any symptoms of elevated body temperatures like fever or dehydration that I have seen charted. During an interview on 8/15/2023 at 10:00 AM, the DON stated Resident #1's PTAC Unit control panel was locked to prevent her from setting the control to 90 degrees. The DON stated Resident #1 had been asked not to turn the setting over 85 degrees due to state regulations and Resident #1 had been non-compliant with the request. The DON stated Resident #7's (roommate) had not complained about the heat because she liked it warm in the room. The DON stated Resident #7's family members had complained about the heat during recent visits and Resident #7 had to be moved to another room. The DON confirmed the padlock was placed on the controls on 7/21/2023 and the family complained after 7/21/2023 about the heat. When asked what the temperature was set on at this time, the DON replied, I believe around 85 degrees, the Maintenance Director monitors the temperature. The DON stated, Residents have a right to control room temperatures within state guidelines[she was unable to quote the state guidelines]. The DON confirmed Resident #1 could not control the temperature of her room due to the control panel being locked. Observations on 8/15/2023 at 10:15 AM revealed, the Maintenance Director measured Resident #1's room temperature at 75 degrees with the PTAC Unit controls set to 83 degrees. During an interview on 8/15/2023 at 10:15 AM, The Maintenance Director stated, The setting on the unit is just a setting, the temperature will not reach 90 degrees when set at 90 degrees, just like the temperature today did not reach 83 degrees. I was told by the Administrator to place a lock on the PTAC Unit in Resident #1's room to prevent the resident from turning the heat up to 90 degrees. The day the lock was placed the room temperature measured 79 degrees [LocalConditions.com revealed the outside temperature on 7/21/2023 at 3:00 PM was 89 degrees F]. I had not been asked to measure the room temperature prior to that day and I have not measured the temperature since placing the lock on the unit. The Maintenance Director confirmed the temperature on the day the padlock was placed on the unit and the temperature today (8/15/2023) did not exceed state regulations. During an interview on 8/15/2023 at 10:26 AM the former Social Services Director (SSD) stated staff reported Resident #1 frequently set the heating unit in her room to 90 degrees. The former SSD stated, I intentionally put [Resident #1 and Resident #7] in the same room because both of them like warmer room temperatures and that made them perfect roommates. The former SSD stated the Administrator ordered the padlock to be placed on the temperature controls in Resident #1's room because 90 degree temperature was too hot and violated state regulations. The former SSD stated she was not aware of any temperature readings taken prior to placing the padlock on the unit. She stated the Administrator ordered the padlock and she did not question the order. During an interview on 8/15/2023 at 1:18 PM, LPN #2 stated Resident #1 frequently complained about being cold and often stated her rights were being violated because she wasn't able to control the temperature of her room. LPN #2 stated she had made the DON aware of Resident #1's complaint related to comfort and her rights being violated. LPN #2 stated Resident #7 never complained of the room being hot because she was comfortable with the temperature (LPN #2 had inquired about her comfort due to warm temps in the room). LPN #2 stated the room temperature was not an issue until Resident #7's health declined and staff had to provide incontinence care more often and staff complained about the temperature of the room being hot during care (staff inconvenience). LPN #2 stated residents have the right to live in an environment that was comfortable to them and staff should not regulate the temperature to suit their comfort level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop a care plan for 2 of 34 sampled residents (Resident #5 and Resident #37). The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 8/30/2022, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Pain Syndrome, and Liver Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. Resident #5 required extensive assistance with bed mobility with two staff. Resident #5 had impairment on one side of his upper and lower extremities. Review of Resident #5's care plan dated 4/8/2021 and 4/9/2021 revealed .has frequent pain 5/10 .he took more pain meds at home .[named Resident #5] is at risk for changes in mood state and psychosocial well-being related to Covid-19 Virus and restricted visitation and community activities . Review of the Physician Orders revealed Resident #5 did not have an order for Suboxone. Review of the Progress Notes dated 4/17/2021 revealed .Staff reported that resident was trying to get them to give him medication out of nightstand. Medication confiscated, which was labeled Suboxone, and locked up in narc [narcotic] box on cart 1. Explained to resident that he was not allowed to have medication brought in from outside the facility. States understanding . Review of the Social Service Note dated 5/14/2021 revealed .Today 1 orange colored round pill (Suboxone) [a medication to assist with cravings and opioid withdrawls] was given to me. This was found in [named Resident #5's] belongings. He has had items brought in by his son on 5/12/2021. This is the second time for this . During an interview on 9/27/2022 at 9:55 AM, the Social Service Director (SSD) stated the staff had found pills in his room on two different occasions. A continued interview with the SSD confirmed she had not implemented a behavioral care plan regarding the family and Resident #5 bringing non-prescribed medications into the facility. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses which included Combined Systolic and Diastolic Heart Failure, and Covid-19. Review of the current physician orders revealed Resident #37 received Zithromax 500 mg (milligram) daily for 5 days for Pneumonia started on 9/23/2022. Paxlovid 300/100 mg twice a day for 5 days for COVID started on 9/23/2022. Rocephin 1 gram intravenously daily for 5 days for infection started on 9/22/2022. Review of Resident #37's current care plan revealed no implementation or interventions for Covid, Pneumonia or antibiotic use. During an interview on 9/27/2022 the Director of Nursing confirmed Resident #37 did not have a care plan implemented or interventions for Covid, Pneumonia or antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to have a Quarterly Care Plan conference meeting with resident/resident representative for 1 of 34 sampled residents (Resident #41) reviewed for care plan conference meeting. The facility also failed to revise a care plan for 1 of 34 sampled residents (Resident #31) reviewed. The findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included Pneumonia, Rheumatoid Arthritis, and Pressure Ulcer Of Sacral Region Stage 3. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) assessment was completed for Resident #41 on 9/12/2022. Review of the medical record for Resident #41 revealed there was no care conference meeting conducted with the resident or resident representative for the assessment on 9/12/2022. During an interview on 9/27/2022 at 11:00 AM, the Social Service Director confirmed she had not completed a care conference meeting with Resident #41 or her representative. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnosis which included Spina Bifida. Review of the Quarterly MDS assessment for Resident #31 dated 8/29/2022 revealed Resident #31 was at risk for developing pressure ulcers/injury with no actual pressure ulcer injury at the time of the MDS assessment dated [DATE]. Review of Resident #31's current Physician Orders revealed, .Santyl Ointment (a medication used to remove dead tissue) 250 UNIT/GM .Apply to anal area topically every shift related to PRESSURE ULCER OF OTHER SITE, STAGE 3 .9/13/2022 . Review of Resident #31's care plan revealed there was no care plan revision to reflect the actual Pressure Ulcer which was diagnosed on [DATE]. During an interview on 9/27/2022 at 7:02 PM the MDS Coordinator confirmed Resident #31's care plan was not revised related to the wound [pressure ulcer] near his rectum until today [9/27/2022]. She stated, it [care plan revision] should have been completed last Tuesday [9/20/2022].

**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 1 of 34 sampled residents (Resident #19) had clean and groomed fingernails. The findings include: Review of the facility policy titled, Care of Fingernails/Toenails, with revision date 10/2010 revealed, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care included daily cleaning and regular trimming . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Dementia, Heart Failure, and Transient Cerebral Ischemic Attacks. Review of the Quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed a Brief Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Continued review of the MDS revealed Resident #19 required total assist of two staff for personal hygiene and bathing. Review of the current Visual/Bedside [NAME] Report for Resident #19 revealed .BATHING/SHOWERING .req [require] ext [extensive] to total assist .Shower 2 x week, bed bath daily .PERSONAL HYGIENE/ORAL CARE .assist her w/ [with] all her hygiene . Observation in Resident #19's room on 9/26/2022 at 10:46 AM, revealed Resident #19's fingernails were not groomed and had dried brown debris under her nails. Continued observation in Resident #19's room on 9/26/2022 at 12:27 PM and 1:30 PM, her fingernails continued to be ungroomed with dried brown debris under her fingernails. During an observation and interview in Resident #19's room on 9/26/2022 at 1:55 PM, the Director of Nursing (DON) confirmed Resident #19's fingernails were ungroomed with dried debris under her fingernails and stated her nails needed to be cleaned and trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility Administrator failed to respond to an identified concern of unauthorized narcotics found on two separate occasions for 1 of 34 residents (Resident #5). The findings include: Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Pain Syndrome, and Liver Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #5 required extensive assistance with bed mobility with two staff. Resident #5 had impairment on one side of his upper and lower extremities. Review of the Progress Notes dated 4/17/2021 revealed .Staff reported that resident was trying to get them to give him medication out of nightstand. Medication confiscated, which was labeled Suboxone, and locked up in narc [narcotic] box on cart 1. Explained to resident that he was not allowed to have medication brought in from outside the facility. States understanding . Review of the Social Service Note dated 4/19/2021 revealed .I spoke with the pt. [patient], due to the report of the nurses finding the Suboxone [treats opioid use disorder and relieves cravings to use and withdrawal symptoms] in his room talked to him about the risks etc. with taking medications that are not being given to him by the staff here. Review of the Social Service Note dated 5/14/2021 revealed .Today 1 orange colored round pill (Suboxone) was given to me. This was found in [named Resident #5's] belongings. He has had items brought in by his son on 5/12/2021. This is the second time for this. I did speak with the Administrator [named Administrator #1] in regard to this. During an interview on 9/27/2022 at 9:55 AM, the SSD stated they had known Resident #5 for a long time, and he was part of the community. The staff had found pills in his room on 2 different occasions. The SSD stated the son had brought Resident #5 two pills and thought Resident #5 had already taken one when the other one was found in the bed on 5/14/2022. The nursing staff realized Resident #5 did not have an order for it. The SSD stated the Suboxone pill was given to her by the DON, and she was instructed to get rid of the pill. The SSD then gave the one Suboxone pill to an unknown nurse to be wasted. During a telephone interview on 9/27/2022 at 3:36 PM, Former Administrator #2 confirmed he and the staff suspected either friend or family were bringing Resident #5 narcotics. Former Administrator #2 confirmed he did not conduct a QAPI (Quality Assurance and Performance Improvement) meeting or developed a PIP (Performance Improvement Plan) for the concern. During a telephone interview on 9/27/2022 at 4:57 PM, Former Administrator #1 confirmed he was not aware of the incidents on 4/17/2022 and 5/14/2022. Continued telephone interview on 9/27/2022 at 4:57 PM, Former Administrator #1 confirmed he was not made aware of and he did not investigate the incidents involving Resident #5. During an interview on 9/27/2022 at 6:35 PM, the current Administrator confirmed there was no documentation of an AdHoc QAPI meeting conducted related to the medication (Suboxone) found in Resident #5's room on April 17, 2021. Continued interview she confirmed there was no evidence an investigation had been conducted into the two instances where Subloxone was found in the possession of Resident #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility QAPI program failed to identify a problem with a resident having access to unauthorized medication and failed to develop an action plan to correct the problem for 1 of 34 residents (Resident #5). The findings include: Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic Pain Syndrome, and Liver Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #5 required extensive assistance with bed mobility with two staff. Resident #5 had impairment on one side of his upper and lower extremities. Review of the Progress Notes dated 4/17/2021 revealed .Staff reported that resident was trying to get them to give him medication out of nightstand. Medication confiscated, which was labeled Suboxone, and locked up in narc [narcotic] box on cart 1. Explained to resident that he was not allowed to have medication brought in from outside the facility. States understanding . Review of the Social Service Note dated 4/19/2021 revealed .I spoke with the pt. [patient], due to the report of the nurses finding the Suboxone [treats opioid use disorder and relieves cravings to use and withdrawal symptoms] in his room talked to him about the risks etc. with taking medications that are not being given to him by the staff here. Review of the Social Service Note dated 5/14/2021 revealed .Today 1 orange colored round pill (Suboxone) was given to me. This was found in [named Resident #5's] belongings. He has had items brought in by his son on 5/12/2021. This is the second time for this. I did speak with the Administrator [named Administrator #1] in regard to this. During an interview on 9/27/2022 at 9:55 AM, the SSD stated they had known Resident #5 for a long time, and he was part of the community. The staff had found pills in his room on 2 diffrent occassions. The SSD stated the son had brought Resident #5 two pills and thought Resident #5 had already taken one when the other one was found in the bed on 5/14/2022. The nursing staff realized Resident #5 did not have an order for it. The SSD stated the Suboxone pill was given to her by the DON, and she was instructed to get rid of the pill. The SSD then gave the one Suboxone pill to an unknown nurse to be wasted. The SSD had reported her findings to the Former DON and Administrator. During a telephone interview on 9/27/2022 at 3:36 PM, Former Administrator #2 confirmed he and the staff suspected either friend or family were bringing Resident #5 narcotics. Former Administrator #2 confirmed he did not conduct a QAPI (Quality Assurance and Performance Improvement) meeting or developed a PIP (Performance Improvement Plan) for the concern. During a telephone interview on 9/27/2022 at 4:57 PM, Former Administrator #1 confirmed he was not aware of the incidents on 4/17/2022 and 5/14/2022 During an interview on 9/27/2022 at 6:35 PM, the current Administrator confirmed there was no documentation of an AdHoc QAPI meeting conducted related to the medication (Suboxone) found in Resident 5#'s room on April 17, 2021. Continued interview she confirmed there was no QAPI meeting conducted until June 2021 concerning the medication [Suboxone] found in the resident's room May 14, 2021 and the incident was only mentioned but no definite plan was put into place to ensure it would not recur in the future. Review of QAPI mintes from meetings held in 2021 revealed no discussion of the incident nor was there evidence any action plan was put in place to correct the problem and ensure it woud not occur again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to post appropriate signage that clearly describes the type of precautions needed and required Personal Protective Equipment (PPE) on a Transmission Based Precautions (TBP) room. The findings include: Review of the facility policy titled, Novel Coronavirus Prevention and Response, revised on 2/6/2022, revealed, .Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE . Observations outside of room [ROOM NUMBER] on 9/26/2022 at 11:15 AM and 5:00 PM, revealed a red square sign with black lettering STOP Isolation Precautions was posted on the door with no specific isolation precautions or what type of PPE was required to enter the room. During an interview on 9/26/2022 at 10:08 AM, the Director of Nursing (DON) confirmed the resident in room [ROOM NUMBER] was on TBP. Observation and interview outside of room [ROOM NUMBER] on 9/26/2022 at 6:47 PM, the Administrator confirmed signage on the door did not state specific isolation precautions or PPE required. She stated The policy is for the sign on the door to state the type of isolation precautions and PPE required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to adequately monitor 10 of 10 sampled residents (Resident #5, #7, #15, #19, #25, #29, #37, #41, #42, #100) reviewed for anticoagulant therapy. The findings include: Review of the facility's policy titled, High Risk Medications-Anticoagulants, dated 1/1/2022, revealed, .This facility recognizes anticoagulants are associated with greater risks of adverse consequences than other medications .The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage . Review of the facility's policy titled, Unnecessary Drugs-Without Adequate Indication for Use, revised 8/30/2022, revealed, .It is the facility's policy that each resident's drug regiment is managed and monitored . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Atrial Fibrillation. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #5 had an order for Eliquis (Apixaban) Tablet (a blood thinning medication) 5 mg (milligrams) by mouth two times a day related to Atrial Fibrillation. Review of Resident #5's Medical Administration Record (MAR) dated September 2022 revealed the resident received Eliquis 5mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Dilated Cardiomyopathy and Atherosclerotic Heart Disease. Review of the 5-day MDS assessment for Resident #7 dated 7/15/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #7 had an order for Eliquis Tablet 5 mg by mouth two times a day related to Atrial Fibrillation. Review of Resident #7's MAR dated September 2022 revealed the resident received Eliquis 5mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. Review of the Significant Change In Status MDS assessment for Resident #15 dated 7/22/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #15 had an order for Eliquis Tablet 2.5 mg by mouth two times a day related to Acute Embolism and Thrombosis. Review of Resident #15's MAR dated September 2022 revealed the resident received Eliquis 2.5mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Heart Failure and Transient Cerebral Ischemic Attacks. Review of the MDS for Resident #19 dated 8/3/2022 revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #19 had an order for Eliquis 5 mg by mouth two times a day related to Transient Cerebral Ischemic Attack. Review of Resident #19's MAR dated September 2022 revealed the resident was receiving Eliquis 5 mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses which included Iron Deficiency Anemia and Atrial Fibrillation. Review of the Quarterly MDS assessment for Resident #25 dated 6/17/2022 revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #25 had an order for Eliquis 5 mg by mouth two times a day related to Atrial Fibrillation. Review of Resident #25's MAR dated September 2022 revealed the resident was receiving Eliquis 5 mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Ischemic Cardiomyopathy, Atherosclerotic Heart Disease, and Coronary Artery Disease. Review of the 5-day MDS assessment for Resident #29 dated 8/23/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #29 had an order for Eliquis 5 mg by mouth two times a day related to Atherosclerotic Heart Disease. Review of Resident #29's MAR dated September 2022 revealed the resident was receiving Eliquis 5 mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include Congestive and Diastolic Heart Failure, Iron Deficiency Anemia and Abnormal Coagulation Profile. Review of the admission MDS assessment for Resident #37 dated 9/5/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #37 had an order for Eliquis 2.5 mg by mouth two times a day related to Abnormal Coagulation Profile. Review of Resident #37's MAR dated September 2022 revealed the resident was receiving Eliquis 2.5 mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease and Acute Embolism and Thrombosis. Review of the 5-day MDS assessment for Resident #41 dated 9/12/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #41 had an order for Eliquis 5 mg by mouth two times a day related to Peripheral Vascular Disease. Review of Resident #41's MAR dated September 2022, revealed the resident was receiving Eliquis 5 mg two times per day. Continued review revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Systolic Congestive Heart Failure and Paroxysmal Atrial Fibrillation. Review of the Quarterly MDS for Resident #42 dated 9/14/2022 revealed the resident received anticoagulant medication 6 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #42 had an order for Eliquis 5 mg by mouth two times a day related to Atrial Fibrillation. Review of Resident #42's MAR dated September 2022 revealed the resident was receiving Eliquis 5 mg two times per day. continued reviuew revealed there was no monitoring for side effects of Eliquis. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses which included Transient Cerebral Ischemic Attack and Sequelae Cerebral Infarction. Review of the Significant Change In Status MDS assessment for Resident #100 dated 7/25/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #100 had an order for Eliquis 5 mg by mouth two times a day related to Sequelae Cerebral Infarction. Review of Resident #100's MAR dated September 2022 revealed the resident received Eliquis 5 mg two times a day. Continued review revealed there was no monitoring for side effects of Eliquis. During an interview on 9/28/2022 at 10:03 AM, the Director of Nursing (DON) confirmed there was no physician's order to monitor side effect of anticoagulants for Residents #5, #7, #15, #19, #25, #29, #37, #41, #42, #100. She stated, We haven't done that since I've been here. During an interview on 9/28/2022 at 11:47 AM, Licensed Practical Nurse (LPN) #4, who had been employed at the facility for 20 years, stated, If a resident is on an anticoagulant, we monitor for side effects such as bleeding and bruising and it's documented on the resident's MAR. She reviewed Resident #41 and Resident #7's MAR, and stated, They are on Eliquis, we don't do monitoring for that. I have never seen monitoring for side effects of Eliquis. Continued interview LPN #4 stated, The care plan may say to monitor, but there's no way to check off that you monitored if it's not on the MAR. I don't look at care plans every day; I only look at them if I have been off a few days. During an interview on 9/28/2022 at 11:59 AM LPN #5, who had been employed at the facility for 7 years, stated, if a resident is on an anticoagulant, then you would monitor for bleeding. She reviewed Resident #37's physician orders and stated, She's on Eliquis and I don't see anywhere to document monitoring of side effects of it. She reviewed the resident's care plan and stated, there's monitoring for side effects on there but I don't look at the care plans unless I am updating them, I don't look at them every day. During a telephone interview on 9/28/2022 at 1:14 PM, the Consultant Pharmacist stated, if a resident is taking Eliquis, I would recommend monitoring for side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the care plan for 1 resident (#58) of 22 residents reviewed. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Polyosteoarthritis, Disorders of Bone Density and Structure, Adjustment Disorder with Depressed Mood, Difficulty Walking and Dementia without Behavioral Disturbances. Medical Record review of Resident #58's Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed Resident #58 had a fall with major injury. Continued review revealed the resident required 2 person assist with transfers. Medical Record review of Resident #58's care plan dated 10/16/18 revealed Resident #58 required a lift for all transfers. Interview with Certified Nursing Assistant (CNA) #2 on 7/23/19 at 7:38 AM in the conference room when asked concerning Resident #58's fall on 6/25/19 revealed she assisted Licensed Practical Nurse (LPN) #1 with putting Resident #58 back in the bed after finding the resident on the floor. When asked how the resident was returned to the bed, CNA #2 stated we lifted [Resident #58] up by the arms and returned [Resident #58] to bed. When asked what the care plan required for transferring Resident #58, CNA #2 stated she was not sure what the care plan required for transferring the resident. Telephone interview with LPN #1 on 7/23/19 at 2:35 PM when asked concerning Resident #58's fall on 6/25/19 revealed he assessed the resident for any injuries and lifted the resident back in bed with the assistance of CNA #2. Continued interview when asked how Resident #58 was transferred back to bed he stated we lifted the resident up with our arms and put the resident back to bed. Continued interview when asked what the care plan required for transferring the resident he stated I am not sure what the care plan required for transferring the resident because the resident never gets out of bed. Telephone interview with LPN #4 on 7/23/19 at 2:45 PM when asked concerning transferring Resident #58 after the fall on 6/25/19 confirmed she witnessed LPN #1 and CNA #2 return Resident #58 back to bed by scooping the resident up with their arms. Interview with the Director Of Nursing on 7/24/19 at 3:00 PM in her office confirmed the care plan for Resident #58 was not followed regarding the use of a lift while transferring Resident #58 from the floor back to bed after a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Polyosteoarthritis, Disorders of Bone Density and Structure, Adjustment Disorder with Depressed Mood, Difficulty Walking, Dementia without Behavioral Disturbances. Medical Record review of Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed Resident #58 had a fall with major injury. Medical Record review of Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed Resident #58 requires a two person assist. Interview with the Director of Nursing (DON) on 7/24/19 at in the conference room confirmed, care plans are to be updated timely with appropriate interventions after daily Interdisciplinary (IDT)meeting. Based on facility policy review, medical record review and interview the facility failed to update/revise care plans for 3 (#4, #8 and #58) of 22 residents reviewed. The findings include: Facility policy, Comprehensive Care Planning Process, undated, revealed .care plans are updated as resident condition changes; resident events occur; or resident's plan of treatment is revised .including monitoring each resident condition and responding with appropriate interventions .Updates are completed by the Department Heads and Unit Managers/Staff Nurse .Staff Nurses are expected to update when Unit Managers are not available . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Venous Insufficiency and Muscle Weakness. Medical record review of the progress note dated 7/4/19 revealed .ALERT SBAR [situation, background, assessment, recomendation] -Fall Note RESIDENT UP TO BATHROOM. UPON EXITING BATHROOM RESIDENT SLIPPED AND FELL LANDING ON RIGHT SIDE FACING BED. Action: ASSESSED FOR INJURY. SKIN TEAR NOTED TO LEFT LOWER OUTER LEG BELOW THE KNEE. ASSISTED BACK TO BED. SKIN TEAR CLEANED WITH Normal Saline [NS], EDGES APPROXIMATED, AND STERI-STRIPS APPLIED . Record review of the facility risk log dated 7/4/19 revealed Resident #4 had a fall. Continued review revealed .Therapy evaluate for balance . Medical record review of Resident #4's care plan revised 5/6/19 revealed no interventions for the 7/4/19 fall. Medical record review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitvely intact. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Unspecified Sequelae of Cerebral Infarction, Major Depressive Disorder, Anxiety Disorder and Peripheral Vascular Disease. Medical record review of Resident #8's Nursing Smoking Screen dated 2/6/19 revealed .Resident need for adaptive equipment .supervision . Medical record review of Resident #8's Nursing Smoking Screen dated 5/2/19 revealed .Resident need for adaptive equipment .smoking apron .supervision . Medical record review of Resident #8's Smoking Safety Evaluation dated 7/15/19 revealed .note: supervision will be required for all residents during designated smoking times .This evaluation will be utilized for the resident's smoking care plan on admission and as indicated .apply smoking apron . Medical record review of Resident #8's Smoking Safety Evaluation dated 7/22/19 revealed .note: supervision will be required for all residents during designated smoking times .This evaluation will be utilized for the resident's smoking care plan on admission and as indicated . Medical record review of Resident #8's care plan revised 5/7/19 revealed no care plan addressing supervision when smoking or the use of a smoking apron. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Polyosteoarthritis, Disorders of Bone Density and Structure, Adjustment Disorder with Depressed Mood, Difficulty Walking and Dementia without Behavioral Disturbances. Medical Record review of Resident #58's Significant Change in Status MDS dated [DATE] revealed Resident #58 had a fall with major injury. Continued review revealed Resident #58 required 2 person total assist with transfers. Medical Record review of Resident #58's care plan dated 10/16/18 revealed no fall interventions for Resident #58's fall on 6/25/19. Interview with Resident #4 on 7/22/19 at 1:36 PM in Resident #4's bedroom revealed the resident had fallen recently while walking from the bathroom to the bed. Interview with Licensed Practical Nurse (LPN) #3 on 7/22/19 at 4:12 PM in the dining room when asked to review Resident #8's Smoking Screen dated 5/2/19 and care plan dated 5/7/19 confirmed I did [Resident #8's] smoking screen but I did not update the care plan; I'm not sure who is supposed to update the care plans. Interview with the Director of Nursing (DON) on 7/22/19 at 4:17 PM in her office confirmed nurses can update care plans as needed and the nurses were responsible to notify the social services or any interdisciplinary team (IDT) member when there's a change in a resident's condition requiring a care plan update; we have IDT meetings each morning and review resident changes and care plan recommendations and update the care plans then; there's a miscommunication; the nurse who did [Resident #8's] smoking assessment failed to notify anyone of the need for [Resident #8] care plan to be updated so the care plan did not get updated. Telephone interview with LPN #1 on 7/23/19 at 2:35 PM revealed the immediate interventions put in place for Resident #58's fall on 6/25/19 were diversional activities. Telephone interview with LPN #5 on 7/23/19 at 2:59 PM when asked concerning updating Resident #4's care plan related to the fall revealed .I notified the family, and faxed the doctor; I updated the care plan on the computer . Interview with the DON on 7/24/19 at 3:00 PM in the conference room confirmed, care plans were to be updated timely with appropriate interventions after the daily IDT meeting and [Resident #58] care plan was not updated. Interview with the DON on 7/24/19 at 3:16 PM in the conference room revealed the staff had to manually update the care plan in the computer. Continued interview when asked to review Resident #4's care plan confirmed anybody can update the care plans. I would think the care plan coordinator would do it, and it wasn't updated.

Based on facility policy review, observation and interview the facility failed to clean 1 of 3 portable water cooler spouts. The findings include: Facility policy review, Cleaning and Sanitizing Equipment, dated 2005 revealed .All equipment is cleaned and sanitized .a. After every use . Observation on 7/22/19 at 10:24 AM on the 200 Hall revealed the portable water cooler #3 had black debris in the spout. Observation on 7/22/19 at 1:44 PM in the dining room revealed the portable water cooler #3 still had black debris in the spout. Interview with Certified Nurse Aide #3 on 7/22/19 10:36 AM on the 200 Hall revealed she had passed water to all the residents on the 100 Hall. Interview and observation with the Dietary Manager present on 7/22/19 at 1:49 PM in the kitchen revealed dietary staff cleaned the water coolers daily. Continued interview when shown the spout confirmed .Nope that is just nasty; I expect them to clean it everyday .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess bed rail use for 1 resident (#33); and failed to accurately assess the origin of the pressure ulcer for 1 resident (#62) of 34 residents reviewed. The findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses included Conversion Disorder with Mixed Symptom Presentation, History of Healed Osteoporosis Fracture, Chronic Pain, and Major Depressive Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed bed rails were used daily and assessed as a physical restraint. Observation on 10/29/18 at 11:40 AM revealed Resident #33 in his room lying on his right side in the bed with 2 half rails located at both sides of the bed by the head in the up position. Further observation revealed the resident used the rail to reposition himself. Interview with Licensed Practical Nurse #5 on 10/30/18 at 11:44 AM in the conference room revealed she was responsible for the MDS data for Resident #33. Further interview confirmed she had incorrectly identified the bed rails as restraints when in fact they were for mobility on the 9/14/18 MDS. Medical record review revealed Resident #62 was admitted to the facility on [DATE], discharged to the hospital on 8/21/18, and readmitted to the facility on [DATE] with diagnoses included Stage 2 Pressure Ulcer was added on 8/24/18; Anemia, Abnormal Weight Loss, Anorexia, Adjustment Disorder with Depressed Mood, and Alzheimer's Disease. Medical record review of the Skin Evaluation form dated 7/25/18, 7/31/18, 8/1/18, and 8/15/18 revealed redness in the perineal and buttocks areas with no open areas noted. Medical record review of the Nursing Admission/readmission Data Collection form dated for the admission on [DATE] revealed .Skin - pinpoint open areas stage 2 (4 sites) on L [Left] buttock .Top - 1 cm [centimeter] x 0.5 cm x 0.1 cm, Middle - 0.6 cm x 0.6 cm x 0.1 cm, Bottom - 0.3 cm x 0.8 cm x 0.1 cm .stage 2 sheared area right buttock .4.5 cm x 3.0 cm . Medical record review of the Significant Change MDS dated [DATE] revealed the .Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry .0 [zero] . Interview with Registered Nurse #1 on 10/30/18 at 2:26 PM in conference room revealed she was the MDS Coordinator. Further interview confirmed the MDS dated [DATE] incorrectly identified the stage 2 pressure ulcers as facility acquired when in fact the resident was readmitted from the hospital with the pressure sites.

**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 have emergency equipment (ambu bag-a hand held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) for 1 of 1 resident (#49) . The findings include: Record review of the facility policy revised 11/2017 Tracheostomy Care revealed no documentation addressing having emergency equipment needed readily assessable in the room of a resident. Medical record review revealed Resident #49 was readmitted to the facility on [DATE] with diagnoses included Unspecified Cerebrovascular Disease, Encounter For Attention To Tracheostomy [is a surgical procedure which consists of making an incision on the front anterior aspect of the neck and opening a direct airway through incision in the trachea (windpipe)], and Chronic Obstructive Pulmonary Disease. Medical record review of the physician orders dated 10/19/18 revealed .Administer oxygen @ [at] 28 % [percent] per trach [tracheostomy] mask (collar) Q [every] shift . Medical record review of the care plan dated 9/13/18 revealed .Resident #49 has ineffective respiratory airway clearance associated with recurrent respiratory failure require vent [ventilator]. He has a trach . Observation on 10/29/18 at 9:44 AM and 3:31 PM and on 10/30/18 at 9:37 AM in Resident #49's room revealed no ambu bag. Observation on 10/29/18, 10/30/18, and 10/31/18 in the dining room revealed a crash cart with two ambu bags in plastic bags hanging on both sides of the crash cart. Observation and interview with Licensed Practical Nurse (LPN) #1 at 9:44 AM in Resident #49's room revealed no ambu bag in the room. Further interview revealed LPN #1 asked are we suppose to have it in his room? The surveyor replied yes, for emergencies. LPN #1 responded will order one from central supply. Interview with the Director of Nursing on 10/31/18 at 10:25 AM in her office revealed, We have a crash cart near by and it has everything on it, that is the closest one . I am not aware of an ambu bag in his room. We are going to have a ambu bag near him.

**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 serve food in a safe and sanitary manner for 1 resident (#11) of 13 residents observed on the 200 hall. The findings include: Review of the undated facility policy Resident Tray Service and Delivery revealed .Bare hand contact with food is prohibited . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses included Alzheimer's Disease, Dementia, Osteoarthritis, and Blindness. Medical record review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 required supervision with meal set up only. Observation of the noon meal on 10/29/18 at 12:33 PM on the 200 hallway revealed Certified Nurse Aide (CNA) #1 removed a sandwich on the meal tray from a plastic bag and cut the sandwich in half using a butter knife. Further observation revealed CNA #1 picked up the sandwich with her bare hand and handed it to the resident. Interview with CNA #1 on 10/29/18 at 12:37 PM in the 200 hallway confirmed gloves were to be worn when handling resident's food. Interview with the Director of Nursing on 10/31/18 at 7:31 AM in her office confirmed gloves were to be worn when handing residents food. She stated staff was not to handle resident's food with their bare hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain oxygen equipment in a sanitary manner for 1 resident (#46) of 9 residents receiving respiratory care. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses included Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction, Congestive Heart Failure, Anxiety and Chronic Obstructive Pulmonary Disease. Medical record review of the Physician Order dated 7/12/18 to the present revealed oxygen at 2 liters per minute per nasal cannula as needed to maintain oxygen saturation greater than 90 percent. Observation on 10/29/18 at 9:33 AM revealed Resident #46 was not in the room and an oxygen concentrator with a heavy accumulation of debris on the top of the concentrator, under the handle. Further observation revealed oxygen tubing stored in a bag dated 10/29/18 was hanging from the concentrator handle. Further observation at 12:12 PM revealed the oxygen concentrator remained with accumulation of debris. Observation on 10/30/18 at 7:40 AM revealed Resident #46 on the bed in his room with the oxygen concentrator on, and the nasal cannula on the floor. The oxygen concentrator remained with an accumulation of debris as the observations on 10/29/18. Further observation on 10/30/18 at 8:23 AM, with Licensed Practical Nurse (LPN) #3 present, revealed the oxygen concentrator was on, had an accumulation of debris present, and the nasal cannula was on the floor. Further observation at 8:30 AM revealed Registered Nurse (RN) #2 entered Resident #46's room and was asked by the surveyor to check the oxygen concentrator. Interview with RN #2 at 10/30/18 at 8:30 AM in Resident #46's room when asked if the oxygen concentrator was clean stated .not so much . Interview with the Director of Nursing on 10/31/18 at 1:40 PM in her office revealed her expectation was for the oxygen concentrators to be clean when in use by a resident.