**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 (Resident #2) residents who were reviewed for respiratory care. 1. The facility failed to ensure Resident #2 had orders for her oxygen therapy. 2. The facility failed to ensure Resident #2's oxygen humidifier was changed when emptied. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.The findings included: Record review of Resident #2's face sheet, dated 08/11/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety disorder, hypertension (high blood pressure), and unsteadiness on feet. Record review of Resident #2's Comprehensive MDS assessment, dated 08/06/25, indicated Resident #2 had a BIMS score of 15 indicating she was cognitively intact. Resident #2's Special Treatment, Procedures, and Programs under Respiratory Treatments did not have oxygen therapy checked. Record review of Resident #2's care plan, dated 08/11/25, reflected it had no respiratory treatment or care included. Record review of Resident #2's physician orders reviewed on 08/11/25 prior to an interview with LVN A, did not indicate any orders for oxygen therapy or related care. Orders were added immediately after the interview with LVN A. During an observation and interview on 08/11/25 at 08:56 AM, Resident #2 was in her bed with her breakfast in front of her. Her nasal cannula was in her nostrils. The oxygen humidifier bottle was dated 08/02/25, was initialed, and was empty. She stated, They act like they don't even know I am on one (humidifier). She stated, they forget to check it. I have to remind them to change it. She stated, One night nurse has.something was buzzing when she came in. She stated, How would it affect me? when asked if it affected her to not have the humidifier changed timely. During an observation on 08/11/25 at 12:01 PM, the oxygen humidifier was still empty, and Resident #2 continued to wear her nasal cannula. During an observation and interview on 08/11/25 at 12:57 PM, Resident #2 asked LVN A if it (oxygen humidifier) was bubbling. LVN A stated, No, the water ran out. I have to get another one. LVN A stated the night shift changed the oxygen humidifier weekly or PRN if it was empty. LVN A stated the risk of not replacing the oxygen humidifier timely could be nose bleeds, shortness of breath, or dry sinuses. LVN A went to the computer to look up Resident #2's orders. She stated there were no orders for her oxygen therapy. She stated, I will put them in now. She stated the nurse that admitted her was responsible for ensuring the orders were in place. She stated the risk to the resident was that the respiratory equipment might not be changed out which could lead to infection. During an interview on 08/11/25 at 1:25 PM, the DON said nursing staff and nursing administration were responsible to ensure orders were in place. The DON stated the oxygen humidifier should be replaced when the water was out or weekly. The DON stated not changing the oxygen humidifier when it was empty could cause dry mucous membranes. The DON stated not having accurate orders in place could cause a change in condition for the resident. Requested Respiratory Care In-services from the DON on 08/11/25 at 1:25 PM, none were provided before exit. Record review of the facility policy titled, Respiratory Services dated 01/07/25 indicated, Service standard; healthcare personnel will provide respiratory care in compliance with current standards of practice.Respiratory services may include.oxygen administration.Respiratory equipment utilized will be maintained per the manufacturer's instructions or physician's orders.respiratory treatments will be administered per current standards.unless otherwise ordered by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records maintained for each resident were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure CNA Z documented that incontinent care was provided for Resident #1 from 6:27 p.m. on 08/09/25 through 6:00 a.m. on 08/10/25. The facility failed to ensure LVN V documented on a nurse progress note on 08/10/25 when Resident #1 was crying in pain, level of pain, and required pain medication. These failures could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 08/11/25 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included left femur (thigh bone) fracture, muscle weakness, unsteadiness on feet, cellulitis (bacterial infection) of buttocks, cognitive communication deficit, and anxiety (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #1's admission assessment dated [DATE] indicated she was usually able to make herself understood and understood others, had moderately impaired cognition (BIMS-12), was dependent for toilet transfer, and was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 06/11/25 indicated she was always incontinent. Interventions included check and change if wet/soiled. Record review of Resident #1's care plan dated 06/11/25 indicated she was always incontinent of bowel movements. Interventions included check for incontinence and clean and dry if wet or soiled. Record review of Resident #1's incontinent care record dated 08/09/25 completed by CNA Z indicated Resident #1 was checked for incontinence of bladder and bowel on 08/09/25 at 6:27 p.m. The record indicated Resident #1 was incontinent. There was no documentation on Resident #1's incontinent care record after 6:27 p.m. Record review of Resident #1's MAR dated 08/10/25 at 1:14 a.m., completed by LVN V indicated she administered Tramadol (opioid used to treat pain) 25 mg tablet. Results were noted as effective at 2:14 a.m. Record review of a nurse progress note dated 08/10/25 at 8:23 a.m., completed by LVN Y indicated Resident #1 was sent out via 911 for evaluation and treatment for a fall at 7:10 a.m. Resident stable with no additional skin issues noted. There was no documentation of Resident #1 being incontinent, being in pain, or staff not being able to provide care. Record review of Resident #1's hospital records dated 08/10/25 indicated dried feces. During an interview on 08/11/25 at 9:43 a.m., RN X said Resident #1 arrived at the ER at approximately 8:07 a.m. on 08/10/25 with dried fecal matter contained to her brief. During an observation and interview on 08/11/25 at 10:57 a.m., Resident #1 was sitting in her wheelchair in the common area adjacent to the nurse's station. She was dressed in clean clothes. She said she was fine and had no complaints of her care. During an interview on 08/11/25 at 11:58 a.m., LVN Y said Resident #1 had feces in her brief when she was found on the floor on 08/10/25 at approximately 7:00 a.m. She said Resident #1 indicated she was in pain and not able to roll over for care. She said staff were not able to provide incontinent care prior to her transfer to the hospital. During an interview on 08/11/25 at 12:01 p.m., CNA W said she started her shift after 6:00 a.m. on 08/10/25. She said Resident #1 did not require incontinent care during her first round. She said she found Resident #1 on the floor at approximately 7:00 a.m. She said Resident #1 had a bowel movement but was in pain and was not able to roll for incontinent care prior to her transfer to the hospital. She said all care that was provided to residents should be documented in the electronic care record. During an interview on 08/11/25 at 12:46 p.m. the DON said there was no documentation of incontinent care for Resident #1 from 6:27 p.m. on 08/09/25 through 6:00 a.m. on 08/10/25. She said the CNAs and nurses were supposed to document the care because they did the hands-on care. She said it was her expectation staff would document care after the care was provided. She said residents were at risk for delayed care if the proper documentation was not completed. During an interview on 08/11/25 at 3:18 p.m., CNA Z said she completed rounds every two hours on 08/09/25 at 6:00 p.m. through 08/10/25. She said she completed incontinent care for Resident #1 at approximately 4:30 a.m. on 08/10/25. She said she did not document the care in Resident #1's care record. She said she was aware she should document care as it was completed. During an interview on 08/11/25 at 3:35 p.m., RN V said Resident #1 was crying and in pain after midnight on 08/10/25. She said she administered pain medication as ordered. She said she checked Resident #1 approximately 1.5 hours later and she was sleeping. She said she did not document Resident #1's status in the nurse progress notes. She said she was aware she should have documented in the nurse progress notes. She said not documenting resident status could delay care or treatment. Record review of the facility policy Incontinence briefs and pad handling dated 11/18/24 indicated .Documentation associated with handling incontinence briefs and pads includes: -date and time of care -name and title of any staff member who assisted with care . Record review of the facility policy Charting and Documentation dated 10/11/21 indicated All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record is primarily electronic; however, there may be some manual documents that are uploaded into the record. 1. The following information is to be documented in the resident's medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 2. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #3) residents reviewed for infection control. 1. CNA B failed to perform hand hygiene while performing incontinent care for Resident #3. These failures could place residents at risk for infection through cross contamination of pathogens. Findings included: 1. Record review of Resident #3's admission Record dated 08/11/25 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Major Depressive Disorder, hypertension (high blood pressure), and constipation. Record review of Resident #3's Comprehensive MDS assessment dated [DATE] reflected her BIMS score was 99 (unable to complete the interview). The other fields of the MDS assessment were not yet filled out except for her diagnoses which included depression, a hip fracture, and hypertension (high blood pressure). Record review of Resident #3's Care Plan reviewed on 8/11/25 reflected it had no information or interventions related to infection control. During an observation and interview on 08/11/25 at 9:49 AM, Resident #3 was awake and lying in bed. CNA B and CNA C entered the room and did hand hygiene, closed the door, and closed the blinds. CNA B and CNA C put on gloves. CNA B lowered the resident's brief and cleaned her perineal area appropriately. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B and CNA C assisted Resident #3 to turn onto her side and CNA B cleaned her buttocks. CNA B rolled the dirty brief inward and threw it away. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B placed a clean brief, adjusted the resident, and covered her. CNA B and CNA C cleaned up the supplies and completed hand hygiene. During an interview with CNA B on 08/11/25 at 9:57AM, she stated she completed hand hygiene first. She stated she would do hand hygiene before, between, and after incontinent care. She stated she realized she had not done hand hygiene after incontinent care and glove changes, and she should have. She stated she was trained to complete hand hygiene after glove changes and when going from a dirty to clean brief. She stated the risk of not performing hand hygiene was that infection could spread. During an interview with LVN A on 08/11/25 at 12:57 PM, she stated hand hygiene should be completed before care, after the change (brief change) itself, and before leaving the room. She stated staff were trained on hand hygiene for infection control purposes. During an interview with the Director of Nursing on 08/11/25 at 1:25PM, she stated the expectation was for the facility staff providing incontinent care to perform hand hygiene before starting care, when changing gloves (such as when the gloves were dirty), and after care. The DON stated the ADON and herself were responsible for training about hand hygiene. The Director of Nursing stated not completing proper hand hygiene could cause cross contamination. Record review of a facility In-service Training Report, dated 07/09/25, reflected: CNA B and CNA C's signatures on the first page. The second page included, .Incontinent Care.7. Remove old brief and place in bag. Remove gloves, wash hands and reapply gloves.10. Remove gloves and place in bag. 11. Wash hands and apply new gloves. 12. Apply new brief or pad 13. Remove gloves and wash hands. Record review of the facility policy titled, Incontinence briefs and pad handling, long-term care dated 11/18/24, reflected .perform hand hygiene, put on gloves.remove and discard your gloves, perform hand hygiene, put on clean gloves.discard soiled brief.remove and discard your gloves.perform hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to document a physician ordered x-ray was completed, the results, or physician notification in Resident #1's medical record. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 01/06/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (decline in cognitive function), pleural effusion (collection of fluid around the lungs), wheezing (high pitched whistle sound made when breathing), delirium due to know physiological condition, atrial fibrillation (abnormal heart rhythm), insomnia (sleep disorder), and anxiety (excessive, persistent, and uncontrollable worry and fear about everyday situations). Record review of Resident #1's quarterly MDS dated [DATE] indicated she was able to make herself understood, usually understood others, and had moderate cognitive impairment (BIMS 9). She used a walker or wheelchair for mobility. She required assistance for all ADLS. She received oxygen therapy. Record review of Resident #1's care plan dated 10/01/24 indicated she had potential for distressed respiratory effort due to SOB. Interventions included check O2 saturations and notify MD if outside parameters. Record review of Resident #1's physician orders dated 10/16/24 indicated O2 at 2-4 L/min per nasal cannula PRN. Record review of Resident #1's physician orders dated 12/31/24 indicated chest x-ray 2 views. Record review of Resident #1's physician note dated 12/31/24 and completed by NP C indicated Resident #1 developed a wet cough this morning. Review of systems indicated breathing problems, cough, and shortness of breath with exertion. O2 SAT 97%. Assessments indicated cough and chronic congestive heart failure. Treatment included chest x-ray and continue Furosemide Tablet 40 MG 1 tablet orally once a day. Record review of Resident #1's x-ray report dated 12/31/24 at 7:17 p.m. indicated right base infiltrate (white opacity(lacking transparency) in the lungs) and effusion (abnormal collection of fluid), worse than prior. Record review of fax confirmation sheet dated 01/01/25 at 10:54 a.m. indicated LVN A faxed Resident #1's x-ray report to the MD B for review. Record review of fax confirmation sheet dated 01/01/25 at 10:56 a.m. indicated LVN A faxed Resident #1's x-ray report to the MD B for review. Record review of Resident #1's clinical notes dated 12/31/24 through 01/02/25 indicated no documentation of physician notification of change of condition and SOB, physician ordered chest x-ray, completion of chest x-ray, results of x-ray or sending results to the physician for review. During an interview on 01/06/25 at 12:10 p.m., LVN A said Resident #1 had a change of condition on 12/31/24 with SOB and NP C ordered chest x-rays. She said the x-rays were completed on 12/31/24 but the results were not received in the facility before she left at 6:00 p.m. She said she returned to the facility on [DATE] and found the results in the portal. She said she faxed the results to the provider's two separate fax numbers and received confirmations the faxes were successful. She said she called the on-call NP and left a message regarding Resident #1's x-ray results. She said she could not recall the on-call NP's name. She said she put the fax confirmation and x-ray results in the binder at the nurse station for physician review. She said she spoke with the RP and showed her the x-ray results. She said the RP did not want Resident #1 sent out to hospital and was in process of considering hospice. She said on 01/02/25 Resident #1 was receiving her O2 via nasal cannula and also received her breathing TX as ordered. She said the x-ray results were still in the binder at the nurse station waiting for physician review. She said it was her error she did not document in Resident #1's chart for 12/31/24, 01/01/25 and 01/02/25. She said Resident #1 was at risk of not receiving care and services when there was missing information in the clinical records. During an interview on 01/07/25 at 11:30 a.m., RD D said she was conducting a clinical chart audit and was not able to determine if Resident #1's physician ordered x-ray was completed. She said she was not able to determine if the x-ray results were received or if the physician was notified of the results because there was no documentation in Resident #1's chart. She said she called the facility on 01/03/25 and directed MDS LVN E to determine if the x-ray was completed, locate the results, and complete a focused assessment of Resident #1. She said MDS LVN E located the x-ray results by the fax machine, conducted a focused assessment of Resident #1 and notified NP C of the results. She said she was not aware the results of the x-ray were available to the facility as of 12/31/24. She said she was not aware LVN A obtained the results from the portal on 01/01/25 or faxed the results to MD B. She said there was no documentation in Resident #1's medical record. She said it was the facility's expectations the nurse on duty would document a physician ordered x-ray was completed, the results, and physician notification in Resident #1's medical record. She said residents were at risk of delayed care or untimely interventions if there was incomplete documentation in the medical record. Record review of the facility's policy Charting and Documentation dated 10/11/21 indicated Documentation in the medical record is primarily electronic; however, there may be some manual documents that are uploaded into the record. 1. The following information is to be documented in the resident's medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 2. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 3. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LVN, physicians, therapists, social workers, administrator, etc.) in accordance with state law and (named facility) service standards. 5. Per (named facility) expectations, the clinical record must contain per shift charting of resident's condition for a minimum of 3 days following incidents. 6. Per (named facility) expectations, the clinical record should include follow-up of resident's condition at least daily while a resident is on antibiotics or antiviral medication. 7. While long term care charting is by exception, it must include all assessments and unexpected outcomes to reflect thorough nursing care of the resident. 9. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician, or other staff, if indicated; and g. the signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents for 1 (Resident #139) of 13 residents reviewed for controlled medications. Resident #139's hydrocodone 5mg / acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) 20 tablets were not accounted for at the time of discharge 09/11/24 and remained unaccounted for 55 days. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings : Record review of a face sheet dated 11/06/24 indicated Resident #139 admitted on [DATE] was [AGE] years old with diagnoses of fractured right hip and fractured right upper arm. The face sheet indicated discharged on 09/11/24 to another facility. The face sheet did not have contact information for the Resident #139. There was contact information for her family (her son) . Record review of physician orders dated September 2024 indicated Resident #139 orders included hydrocodone 5 mg/ acetaminophen 325 mg as needed for pain with start date of 08/22/24. Record review of the MAR dated September 2024 indicated Resident #139 received a hydrocodone 5 mg/ acetaminophen 325mg by mouth on 09/01/24, 09/04/24 and 09/07/24. Record review of the annual MDS assessment dated [DATE] for Resident #139 was cognitively intact. She had fractures and received an opioid (pain medication) during the last 7 days. Record review of the care plan dated 09/02/24 indicated Resident #139 had pain related to her fractured right leg and right arm. Intervention included she would receive medications per physician's orders. Record review of physician orders dated September 2024 indicated Resident #139 orders included hydrocodone 5 mg/ acetaminophen 325 mg as needed for pain with start date of 08/22/24. Record review of the MAR dated September 2024 indicated Resident #139 received a hydrocodone 5 mg/ acetaminophen 325mg by mouth on 09/01/24, 09/04/24 and 09/07/24. During an observation and interview on 11/5/24 at 9:50 a.m., the interim DON A opened the cabinet and said the cabinet was in his office and was used to store narcotics for destruction. He said this was the first time he had opened this cabinet. The cabinet was secured with 2 locks and was empty. He pointed at the logbook and said when a narcotic was placed in the cabinet, staff logged in the medication. The logbook contained a stack of blank logs and there was an undated log form that had 2 narcotic medications listed on the form. The interim DON A said he had not seen that page before and said he would find out where the narcotics were atheld. He said there was another interim DON B before he was hired last week, and she might know where those narcotics were at. Record review of the undated log record indicated there should have been 2 cards or bottles containing 20 narcotics each. The log indicated date dispensed on: *08/22/24 RX#2028970, hydrocodone (norco) 20 tablets and *09/06/24 RX # 2041187- 20 tablets of Xanax 0.5mg (antianxiety narcotic). During an interview on 11/05/24 at 10:30 a.m., the interim DON B said she was a corporate regional RN, and she had been the acting interim DON after the last DON was terminated. She said she had not opened the narcotic cabinet while she was the interim DON at this facility. She said she had not been given any narcotics for destruction and had not destroyed any narcotics. She said any narcotics not released to residents or family upon discharge or narcotics which had been discontinued, would be given to the DON. The interim DON B said the narcotics would be logged in and placed in the double locked cabinet and would be destroyed with DON, a nurse or administrator and the pharmacist. During an interview on 11/05/24 at 12:30 p.m., the interim Administrator said his expectation was for the narcotics to be kept in a secured manner per the facility policy and they were looking for the 2 narcotics prescriptions that were misplaced or missing. He said they had reached out to the pharmacy to identify who the residents were, and they were interviewing the staff who had discharged the residents who the narcotics was prescribed to. Attempted an interview on 11/05/24 at 2:30 p.m., No answer Resident #139's family phone. A detailed message with the surveyor's contact information was left on the answering machine. During an interview on 11/05/24 at 3:30 p.m. the interim DON A said they had located some narcotics which had been placed in a treatment cart and should not have been stored there. He said one of the missing medication was located. He said the 20 tablets of the prescription of hydrocodone 5mg/325 mg for Resident #139 had not been located. He said they were still investigating and had a call out to the family for Resident #139 who had been discharged on 09/11/24 to a local rehabilitation hospital. During an interview on 11/06/24 at 9:30 a.m., the case manager of the rehabilitation hospital where Resident #139 was discharged said the facility had called yesterday evening about this medication and this hospital did not receive the hydrocodone for Resident #139. She said the physician here had ordered Resident #139 hydrocodone 7.5mg/325 mg during her stay here. The case manager said Resident #139 had not required any pain medication during her stay there and had since been discharged home. She said no narcotics were received. If they had been received the pharmacy would have logged the medication into our system. During an interview on 11/06/24 at 10:00 a.m., LVN C said she was in orientation when Resident #139 discharged on 09/11/24. She said normally if the medications were sent with the resident, she would normally print a list of meds and write down how many were sent home. She said she did not remember the discharge for Resident #139. She said she might have sent a list with the resident and did not make a copy. She said she did not remember anything about the resident or the discharge. She said during her orientation the ADON was here. During an interview on 11/06/24 at 10:15 a.m., the ADON said she did not remember a lot about the discharge for Resident #139 however she said the previous DON had told her not to send medications when residents went to the rehab hospital. She said she never saw Resident #139's medications during the discharge on [DATE] or after that day. During an interview on 11/06/24 at 10:20 a.m. the interim Administrator said they could not locate the narcotic for Resident #139 and the facility reported the incident of the missing medication to the state and local police. He said the family of Resident #139 had never returned his call. He said, We must have an issue with the drugs being stored for destruction. During an interview on 11/06/24 at 1:00 p.m., the interim DON A said his expectation for the narcotics were to be turned into the DON or interim DON and he was training all the nurses on the new policy. He said they did not have a policy and procedure prior to the DON receiving the narcotics for destruction. Record review of the policy dated 11/05/24 titled Narcotics indicated . All active and discontinued Narcotic meds will be left on the cart and counted each shift until the DON is available to receive or take off the cart. When a resident is discharged with narcotics 2 nurses and the family or who is receiving the narcotics has to sign the narcotic count sheet and note the number given and the sheet placed in the scanning bin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 residents (Resident #136) reviewed for infection control. LVN C failed to wear a gown during wound care for Resident #136 who was on Enhanced Barrier Precautions (EBP). This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #136's face sheet dated 11/06/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included elevated white blood cell count (when the body produces more white blood cells than normal which could be caused by infection) and stage 3 (a deep wound that extends through the skin and into the subcutaneous tissue) pressure ulcer (a localized injury to the skin and soft tissue that occurs when an area of skin is under sustained pressure). Record review of an admission MDS dated [DATE] indicated Resident #136 had moderately impaired cognition. The MDS had not been completed and had no further information. Record review of a care plan dated 11/05/24 indicated Resident #136 had a stage 3 ulcer to her sacrum and staff were to utilize EBP which included wear gloves and gown during wound care of any skin opening requiring a dressing. During an observation on 11/04/24 at 9:45 a.m., Resident #136's door had a sign instructing she was on EBP and a supply cart containing needed PPE (a type of clothing or equipment that protects people from injury or illness in the workplace). During an observation on 11/05/24 at 3:25 p.m., LVN C prepped her supplies on a sterilized bedside table in Resident #136's room. She washed her hands and put on gloves. She then returned to the bedside and unfastened Resident #136's brief, rolled her to her right side and removed a dressing from her sacral wound. She washed her hands and put on clean gloves. She cleansed the wound using wound cleanser and gauzed, patted the area dry with gauze, applied collagen powder mixed with an antimicrobial skin wound gel, and covered with a border dressing. LVN removed her gloves, washed her hands and exited the room. During an interview on 11/05/24 at 3:57 p.m., LVN C said she forgot to put on a gown while doing wound care for Resident #136. She said she realized she had not worn the gown when she finished the wound care. She said she had been in a hurry because she had so much that she needed to get done. LVN C said a gown and gloves were always required when doing wound care or having direct contact with a resident on EBP and Resident #136 was on EBP due to having an open wound. She said not wearing a gown when giving care to a resident on EBP could result in cross contamination to other residents. She said she was given training on EBP during her orientation a few months ago. During an interview on 11/05/24 at 4:02 p.m., the interim DON said his expectation was for all nursing staff to glove and gown when giving care requiring direct contact with a resident on EBP. He said all nursing staff had been trained on the requirements of EBP. He said not wearing appropriate PPE during direct contact care to a resident on EBP could cause cross contamination to other residents and staff. During an interview on 11/06/24 at 1:15 p.m., the interim Administrator said he expected all staff to follow CMS guidelines for EBP including donning and doffing appropriate PPE and hand hygiene. He said the interim DON was ultimately responsible for monitoring EBP, but all department heads made rounds daily and had been trained on EBP. He said a possible negative outcome of not following the guidelines for EBP could be the transfer of disease or illness to other residents and staff. Record review of a facility policy titled Isolation Categories of Transmission-Based Precautions and Enhanced Barrier Precautions revised 10/23/24 indicated, . Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care areas that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Examples of high contact resident care activities requiring gown and glove use for enhanced barrier precautions include: . Wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately notify the resident physician regarding a change in a resident's condition for one (Resident #1) of seven residents reviewed for changes in condition. The facility failed to inform the physician immediately of Resident #1's witnessed fall on 12/15/2023. This failure could place residents' physician at risk of not being aware of any changes in their conditions and could result in a delay in treatment and a decline in residents' health and well-being. The findings included: Record review of Resident #1's face sheet dated 10/15/24 indicated an [AGE] year-old female with an admission date of 10/18/23 with diagnoses of Alzheimer's disease unspecified, muscle weakness (Generalized), and other abnormalities of gait and mobility. Record review of Resident #1's admission MDS dated [DATE] indicated she was understood and understood others and she had a moderate cognitive impairment (BIMS score of 6). She required supervision or moderate assistance for most ADLs. She had at least one fall in the last month prior to admission/entry or reentry to the facility. She was frequently incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #1's care plan, revised on 11/12/2023, indicated the resident had a history of falls since admission related to poor safety awareness due to Alzheimer's. The interventions included to engage resident in activities that improve strength, balance, and posture as tolerated and document results, keep nurse call bell within easy reach or instruct resident to use call bell or call out for assistance, instruct resident on safety measures to reduce the risk of falls, keep areas free of obstructions to reduce the risk of falls or injury, keep personal items within reach, and the bed was to be in low position with wheels locked. Record review of the facility's Incident/Accident Log dated 12/01/2023 through 12/31/2023 indicated no history of falls for Resident #1. Incident log indicated an injury of unknown origin reported on 12/19/2023. Record Review of Resident #1's incident report dated 12/19/2023 authored by LVN A indicated that the nurse noted resident to have bruising and swelling to the right eyebrow area while sitting in her wheelchair in the common area, resident said I'm fine and denied any pain or discomfort. Record review of Resident #1's progress notes reviewed from 12/01/2023 through 12/31/2023 found no progress notes or incident reports indicating Resident #1 was assessed by LVN C for injuries following a witnessed fall observed by CNA B on 12/15/2023 and/or documentation that the physician was notified of the witnessed fall. Resident #1, no longer resides at facility, attempted to call Resident #1 and/or FM via telephone on 10/16/2024 at 5:15 p.m. and 6:15 p.m., attempts were unsuccessful with no answered or returned phone calls. During an interview on 10/16/2024 at 10:00 a.m., the Executive Director said she was the administrator at the time of the incident with Resident #1. During her investigation with the report of Resident #1 having an injury of unknown origin on 12/19/2023, she found that Resident #1 had a witnessed fall observed by CNA B on 12/17/2023.This was reported to LVN C, but she failed to complete an incident report and/or document in the resident's medical records regarding the fall. She said that the incident happened at shift change and due to poor communication (on coming shift thought out going shift was notified and aware of the incident) the incident was not documented. She said the staff were provided an in-service regarding completing incident reports and reporting incidents to physicians. She said not reporting changes to the physician could result in a delay in resident's treatment. During an interview on 10/16/2024 at 4:52 p.m., LVN A said on 12/19/2023 she noticed bruising and swelling to Resident #1's right eye/eyebrow area. She said Resident #1 did not show grimace or signs of pain at that time. She said she completed an incident report for injury of unknown origin and incident was reported immediately to the DON, the AC, the MD, and the RP. LVN A said that Resident #1 had a history of falls, and that the MD did not give any new orders when the fall was reported on 12/19/2023. She said during interviews and conversations with other staff and the family it was later found that the resident had a witnessed fall observed by CNA B on 12/17/2023 which could have caused the bruise and swelling to Resident #1's right eye/eyebrow area. LVN A said she had received training on reporting incidents to the the NP/MD and completion of incident reports. CNA B, no longer employed at the facility, was attempted to be reached via telephone on 10/16/2024 at 5:00 p.m. and 6:00 p.m., attempts were unsuccessful with no answered or returned phone calls. Record review of a witness statement provided by CNA B indicated on 12/17/2023 at around 6:10 p.m., CNA B was arriving to work. Resident #1 requested CNA B take her to the restroom. CNA B assisted Resident #1 to the restroom, and when she was finished in the restroom, she assisted her to her wheelchair and started wheeling her back to the sitting area. Resident #1 said she had forgotten her purse in the restroom and asked CNA B to retrieve her purse for her. CNA B returned to the restroom to retrieve the purse, and when she was coming out of the restroom, she observed Resident #1 standing up from her wheelchair and falling. and CNA B ran to her and attempted to reach her to prevent a fall but was unsuccessful, and Resident #1 fell, hitting the side of her forehead. CNA B stated Resident #1 was getting herself up, saying nothing happened. Resident #1 was assisted back in her wheelchair, and LVN C was notified of the incident. During an interview on 10/17/2024 at 10:45 a.m., LVN C said when she began her shift at 6:00 p.m. on 12/17/2023, CNA B reported to her that Resident #1 had a fall or near fall. LVN C said she conducted a head-to-toe assessment after CNA B reported the incident and she did not observe any injuries nor did the resident grimace or make sounds of pain when she was assessing her. LVN C said Resident #1's family and private sitter were present during the assessment and was aware of the fall/near fall incident and made light of the situation (no concerns). She said that she initially thought the incident had happened on the prior shift and the other shift had completed the incident report and documentation. She said she got busy during her shift and failed to review the chart for the incident report or document the head-to-toe assessment she completed. LVN C said she was later questioned about the incident, and it was found that Resident #1 fell at shift change and that she was responsible for completing the incident report and reporting the incident to the physician, which she failed to do. She said she received training on completing incident reports and notifying the physician of accidents/injuries. She said not reporting incidents to the physician could delay the resident's treatment. During an interview on 10/17/2024 at 2:30 p.m., the interim DON said she had only been at the facility for a little over a week as interim DON, but her expectations were if a resident had a fall that the resident be assessed immediately by licensed facility staff and the fall and assessment findings be reported to the MD/NP, the ADON, herself, the Administrator, and the RP, if applicable. The DON said that the NP/MD would dictate what happened next with new orders (x-rays, to local ER for evaluation, medications). The DON said the facility staff should initiate the incident reporting process (incident report, neuro checks, changes, skin assessments, etc.) and document for 72 hours in the resident electronic medical records to identify any changes/concerns. The DON said staff should make sure all incident care and follow up care was documented in the resident's medical record. The DON said that not reporting the incident to MD/NP could delay the resident's treatment plan. During an interview on 10/17/2024 at 3:00 p.m., the Administrator said that he had only been the interim Administrator for about one week, but his expectation was if a resident had a fall that the resident would be assessed immediately by licensed staff and the fall assessment would be reported to the physician/NP, the family, and the supervisor. The facility licensed staff should initiate the incident reporting process and document all findings in the resident's electronic medical record. The Administrator said that the electronic medical records should include an incident report, clinical documentation, who was notified of the incident, and complete documentation of the incident. The Administrator said that the resident involved in the incident should be assessed routinely until resolution and follow up from physician received. The Administrator said that not reporting the incident to MD/NP could delay the resident's treatment. Record Review of Facility's In-Service Training Report Titled January Nursing Meeting dated 01/25/2024 indicated, Incident reports: All incident reports need to be done immediately when an incident occurs. This includes the entire incident process including risk assessments, neuro checks (if the fall is unwitnessed and the patient is unable to tell you if they hit their head or not neuro checks must be started.) Every shift is responsible for completing your section on the report. Record review of the facility's Notification of Changes policy, revised July 16, 2024, indicated 1. The nurse will immediately notify the resident/resident responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive) an accident involving residents, which result in injury and has the potential for requiring physician intervention . 2. The nurse will notify the resident/resident's representative and the resident's physician for non-immediate changes of condition in a timely manner 3. Document the notification and record any new orders in the resident's medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN C documented Resident #1's change of condition and physician notification on 12/17/2023. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 10/15/24 indicated an [AGE] year-old female with an admission date of 10/18/23 with diagnoses of Alzheimer's disease unspecified, muscle weakness (Generalized), and other abnormalities of gait and mobility. Record review of Resident #1's admission MDS dated [DATE] indicated she was understood and understood others and she had a moderate cognitive impairment (BIMS score of 6). She required supervision or moderate assistance for most ADLs. She had at least one fall in the last month prior to admission/entry or reentry to the facility. She was frequently incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #1's care plan, revised on 11/12/2023, indicated the resident had a history of falls since admission related to poor safety awareness due to Alzheimer's. The interventions included to engage resident in activities that improve strength, balance, and posture as tolerated and document results, keep nurse call bell within easy reach or instruct resident to use call bell or call out for assistance, instruct resident on safety measures to reduce the risk of falls, keep areas free of obstructions to reduce the risk of falls or injury, keep personal items within reach, and the bed was to be in low position with wheels locked. Record review of the facility's Incident/Accident Log dated 12/01/2023 through 12/31/2023 indicated no history of falls for Resident #1. Incident log indicated an injury of unknown origin reported on 12/19/2023. Record Review of Resident #1's incident report dated 12/19/2023 authored by LVN A indicated that the nurse noted resident to have bruising and swelling to the right eyebrow area while sitting in her wheelchair in the common area, resident said I'm fine and denied any pain or discomfort. Record review of Resident #1's progress notes reviewed from 12/01/2023 through 12/31/2023 found no progress notes or incident reports indicating Resident #1 was assessed by LVN C for injuries following a witnessed fall observed by CNA B on 12/15/2023 and/or documentation that the physician was notified of the witnessed fall. During an interview on 10/16/2024 at 10:00 a.m., the Executive Director said she was the administrator at the time of the incident with Resident #1. During her investigation with the report of Resident #1 having an injury of unknown origin on 12/19/2023, she found that Resident #1 had a witnessed fall observed by CNA B on 12/17/2023.This was reported to LVN C, but she failed to complete an incident report and/or document in the resident's medical records regarding the fall. She said that the incident happened at shift change and due to poor communication (on coming shift thought out going shift was notified and aware of the incident) the incident was not documented. She said the staff were provided an in-service regarding completing incident reports and reporting incidents to physicians. She said not reporting changes to the physician could result in a delay in resident's treatment. During an interview on 10/16/2024 at 4:52 p.m., LVN A said on 12/19/2023 she noticed bruising and swelling to Resident #1's right eye/eyebrow area. She said Resident #1 did not show grimace or signs of pain at that time. She said she completed an incident report for injury of unknown origin and incident was reported immediately to the DON, the AC, the MD, and the RP. LVN A said that Resident #1 had a history of falls, and that the MD did not give any new orders when the fall was reported on 12/19/2023. She said during interviews and conversations with other staff and the family it was later found that the resident had a witnessed fall observed by CNA B on 12/17/2023 which could have caused the bruise and swelling to Resident #1's right eye/eyebrow area. LVN A said she had received training on reporting incidents to the the NP/MD and completion of incident reports. CNA B, no longer employed at the facility, was attempted to be reached via telephone on 10/16/2024 at 5:00 p.m. and 6:00 p.m., attempts were unsuccessful with no answered or returned phone calls. Record review of a witness statement provided by CNA B indicated on 12/17/2023 at around 6:10 p.m., CNA B was arriving to work. Resident #1 requested CNA B take her to the restroom. CNA B assisted Resident #1 to the restroom, and when she was finished in the restroom, she assisted her to her wheelchair and started wheeling her back to the sitting area. Resident #1 said she had forgotten her purse in the restroom and asked CNA B to retrieve her purse for her. CNA B returned to the restroom to retrieve the purse, and when she was coming out of the restroom, she observed Resident #1 standing up from her wheelchair and falling. and CNA B ran to her and attempted to reach her to prevent a fall but was unsuccessful, and Resident #1 fell, hitting the side of her forehead. CNA B stated Resident #1 was getting herself up, saying nothing happened. Resident #1 was assisted back in her wheelchair, and LVN C was notified of the incident. During an interview on 10/17/2024 at 10:45 a.m., LVN C said when she began her shift at 6:00 p.m. on 12/17/2023, CNA B reported to her that Resident #1 had a fall or near fall. LVN C said she conducted a head-to-toe assessment after CNA B reported the incident and she did not observe any injuries nor did the resident grimace or make sounds of pain when she was assessing her. LVN C said Resident #1's family and private sitter were present during the assessment and was aware of the fall/near fall incident and made light of the situation (no concerns). She said that she initially thought the incident had happened on the prior shift and the other shift had completed the incident report and documentation. She said she got busy during her shift and failed to review the chart for the incident report or document the head-to-toe assessment she completed. LVN C said she was later questioned about the incident, and it was found that Resident #1 fell at shift change and that she was responsible for completing the incident report and reporting the incident to the physician, which she failed to do. She said she received training on completing incident reports and notifying the physician of accidents/injuries. She said not reporting incidents to the physician could delay the resident's treatment. During an interview on 10/17/2024 at 2:30 p.m., the interim DON said she had only been at the facility for a little over a week as interim DON, but her expectations were if a resident had a fall that the resident be assessed immediately by licensed facility staff and the fall and assessment findings be reported to the MD/NP, the ADON, herself, the Administrator, and the RP, if applicable. The DON said that the NP/MD would dictate what happened next with new orders (x-rays, to local ER for evaluation, medications). The DON said the facility staff should initiate the incident reporting process (incident report, neuro checks, changes, skin assessments, etc.) and document for 72 hours in the resident electronic medical records to identify any changes/concerns. The DON said staff should make sure all incident care and follow up care was documented in the resident's medical record. The DON said that not reporting the incident to MD/NP could delay the resident's treatment plan. During an interview on 10/17/2024 at 3:00 p.m., the Administrator said that he had only been the interim Administrator for about one week, but his expectation was if a resident had a fall that the resident would be assessed immediately by licensed staff and the fall assessment would be reported to the physician/NP, the family, and the supervisor. The facility licensed staff should initiate the incident reporting process and document all findings in the resident's electronic medical record. The Administrator said that the electronic medical records should include an incident report, clinical documentation, who was notified of the incident, and complete documentation of the incident. The Administrator said that the resident involved in the incident should be assessed routinely until resolution and follow up from physician received. The Administrator said that not reporting the incident to MD/NP could delay the resident's treatment. Record Review of Facility's In-Service Training Report Titled January Nursing Meeting dated 01/25/2024 indicated, Incident reports: All incident reports need to be done immediately when an incident occurs. This includes the entire incident process including risk assessments, neuro checks (if the fall is unwitnessed and the patient is unable to tell you if they hit their head or not neuro checks must be started.) Every shift is responsible for completing your section on the report. Record review of the facility's Notification of Changes policy, revised July 16, 2024, indicated 1. The nurse will immediately notify the resident/resident responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive) an accident involving residents, which result in injury and has the potential for requiring physician intervention . 2. The nurse will notify the resident/resident's representative and the resident's physician for non-immediate changes of condition in a timely manner 3. Document the notification and record any new orders in the resident's medical records .

Based on interview and record review, the facility failed conduct initially a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 calendar days of admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition for 2 of 7 residents (Residents #1 and #2) reviewed for comprehensive assessments and timing. The facility failed to ensure a MDS Assessment for Residents #1 and #2 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet dated 02/21/2024 reflected an admission date of 02/01/2024 with diagnoses that included Nontraumatic Subarachnoid Hemorrhage (bleeding in the space that surrounds the brain), Nontraumatic intracerebral Hemorrhage, Intraventricular (the eruption of blood in the cerebral ventricular system), Myasthenia Gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), Dysphagia (difficulty or discomfort in swallowing), Dementia (loss of cognitive functioning), and weakness to both legs. Record review of Resident #1's admission MDS indicated in Section A - A1600 Entry Date 02/01/2024 and Section Z Assessment Administration - Z0400 A. Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A, C, D, B, E, F, J Date sections completed 02/05/2024 and Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A,B , E, GG, H, I, J, K, L, M, N, O, P, Q, Z Date completed 02/20/2024. Z 0500 Signature of RN Assessment Coordinator Verifying Assessment Completion Signature as DON on 02/20/2024 (6 days late). Record review of Resident #2's face sheet dated 02/26/2024 reflected an admission date of 02/10/2024 with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Atrial Fibrillation (a type of irregular heartbeat), Hypertension (A condition in which the force of the blood against the artery walls is too high), and Congestive Heart Failure (condition that happens when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #2's admission MDS indicated in Section A - A1600 Entry Date 02/10/2024 and Section Z Assessment Administration - Z0400 A. Signature of Persons Completing the assessment or entry/death report Signature: MDS Coordinator Title LVN, RAC-CT, Sections: A Date sections completed 02/16/2024, no additional signatures or sections identified as completed, no signature or date on Z 0500 Signature of RN Assessment Coordinator Verifying Assessment Completion. The admission MDS was not completed as of 2/26/2024. During an interview on 02/26/2024 at 1:11 pm, the MDS Coordinator stated she was responsible for completing all MDS assessments. The MDS Coordinator stated the admission MDS assessment should be completed within 14 days of admission. The MDS Coordinator stated, she is behind on completing MDS, she has been out of the facility for training last week and she is the only staff member completing the MDS/comprehensive assessments, trying to get caught up. The MDS Coordinator said she was working on getting all the MDS/comprehensive assessments completed, the management staff and corporate staff would be helping with the completion of overdo MDS/comprehensive assessments. She said that the incomplete admission MDS could put the resident at risk for improper or incorrect care. She stated the facility followed RAI (resident assessment instrument). During an interview on 02/26/2024 at 3:45 pm, the Administrator stated the facility followed the RAI manual guidelines for MDS assessments. The Administrator stated she expected the admission MDS to be completed within 14 days. The Administrator stated the MDS Coordinator was responsible for completing all MDS assessments but would get staff to help complete overdo MDS assessments. The Administrator stated it was important to complete the MDS assessment timely to ensure the regulations were followed and residents receive proper care. Record Review of the facility's Minimum Data Set (MDS) policy and procedure, revision date of 01/23/2024, indicated Service Standard: facility retirement system communities will complete accurate resident assessments and submit assessments in accordance with current federal and state submission time frames. 1. All associates responsible for completion of the MDS will be educated on the proper assessment and date entry codes in accordance with the MDS RAI manual. 2. The MDS coordinator will ensure the appropriate edits are made prior to submitting the MDS data. 3. Timeframes for completion and submission of assessments is based on current requirements published in the Rai manual. Record review of the mds-3.0-rai-manual-v1.18.11_October_2023 indicated The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 7 residents reviewed for comprehensive plans of care. (Resident #3) The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment or no more than 21 days after admission for Resident #3. This failure could place residents at risk of not receiving appropriate care and services. Findings included: Record review of Resident #3's face sheet dated 02/26/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease with (acute) exacerbation (a lung disease that blocks airflow making it difficult to breathe), pneumonia (an infection that inflames the air sacs in one or both lungs), gastro-esophageal reflux disease (stomach contents leak backward from the stomach into the esophagus (food pipe)), muscle weakness, limited activity due to disability, and cognitive communication deficit. Record review of the clinical record from 01/24/2024 to 02/26/2024 for Resident #3 revealed no comprehensive care plan. During an interview on 02/26/2024 at 1:11 pm, the MDS Coordinator said Resident #3's comprehensive care plan was not completed and said, must have missed it. The MDS Coordinator said she was in the process of completing overdo MDS and comprehensive care plans. She said the care plan was not completed and available to staff. She said the facility nursing staff (ADON, DON, or CN) usually reviewed and completed the care plans after they were initiated in the computer. The MDS Coordinator said not having a comprehensive care plan in the medical records could put the resident at risk for receiving appropriate and adequate care. During an interview and record review 02/26/2024 at 3:20 pm, the DON was unable to locate a comprehensive care plan for Resident #3 in the electronic medical record. The DON said when a resident admitted to the facility there was a basic care plan in the computer. She said once the MDS/Comprehensive Assessment was completed then an IDT/care plan meeting was scheduled, and a comprehensive care plan was developed and should happen within 7 days of the compressive assessment completion. She said Resident #3's comprehensive care plan should have been completed by no later than 02/13/2024. The DON said not having a comprehensive care plan could put resident at risk for not receiving care, missing care, or appropriate/adequate care. During an interview 02/26/2023 at 3:30 pm, requested a facility policy for comprehensive care plans and the Administrator said the facility does not have a policy for comprehensive care plans, they follow the RAI manual. Record review of the mds-3.0-rai-manual-v1.18.11_October_2023 indicated The care plan completion date must be no later than 7 calendar days after the comprehensive assessment completion date (CAA(s) completion date = 7 calendar days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 7 residents reviewed for accurate medical records. The facility staff (RN B) failed to document on the admitting orders and MAR/TAR regarding Resident #1's indwelling Foley catheter care and maintenance, PICC line care and maintenance, and enteral feeding dosing upon admitting to the facility. The facility staff (LVN A) failed to document an accurate assessment of a new wound identified on 02/05/2024. The facility staff (RN B) failed to ensure physician's orders were written for removing a PICC line on 02/05/2024. These failures could place resident at risk of having errors in care and treatment decisions being based on incomplete and inaccurate medical records. Findings included: Record review of face sheet dated 02/21/2024 indicated Resident #1 was admitted on [DATE], was a [AGE] year-old female with diagnoses that included nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), nontraumatic intracerebral hemorrhage, intraventricular (the eruption of blood in the cerebral ventricular system), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), dysphagia (difficulty or discomfort in swallowing), dementia (loss of cognitive functioning), and weakness to both legs. Record review of Resident #1's hospital discharge instructions note dated 02/01/2024 indicated the resident's discharge diet was by tube feeding (G-tube - a tube inserted through the belly that brings nutrition directly to the stomach): Paptamen AF 95 ml/hr. Patient Discharge condition indicated the resident had a G-tube, indwelling Foley catheter (catheter inserted for continuous drainage of the bladder), and a double lumen (two ports) PICC line (thin flexible tubing inserted into a vein in the upper arm threaded into a large vein above the right side of the heart) to left arm upon discharge. Record review of Resident #1's initial MDS assessment dated [DATE], indicated the resident had a memory problem and cognitive skills for decision making were severely impaired. The resident did not have any pressure injuries at the time of admission. The resident had an indwelling urinary catheter and received nutrition through parenteral or tube feedings. Record review of Resident #1's chart reflected there was no comprehensive care plan developed. The initial care plan dated 02/02/2024 indicated the resident had an alteration/potential alteration in nutrition with goals to maintain weight and meet nutritional needs at highest practicable level. The interventions included for the resident to be NPO and a diet order for G-tube feedings of Isosource upon admission. The resident did not have any pressure injuries addressed on the initial care plan. Record review of Resident #1's MAR (Medication Administration Record)/TAR (Treatment Administration Record) indicated no orders, treatments or interventions for Resident's # 1 indwelling foley catheter, PICC line and enteral feeding dosing was documented upon admission to the facility. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/01/2024 at 7:30 pm, authored by RN B, the Nurse Summary indicated: Patient here from local hospital post fall/subarachnoid hemorrhage. The resident had a history of: dementia, Alzheimer's, subarachnoid hemorrhage, myasthenia gravis, stroke, and pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). The resident was NPO after failing a swallow study and had a G- tube. The tube was secured in place with an adhesive holder on the abdomen, abdominal binder covering G-tube site. The resident had an indwelling urinary Foley catheter and Podus boots (multi-purpose foot boot helps in the healing and prevention of hell and toe ulcers and safeguards against foot drop) on both feet to protect her heels. No breakdown was noted on her heels. Mild redness was noted on her buttocks. The resident had a left upper arm double lumen PICC line with the dressing in place. Record review of Resident #1's Skilled Daily Nurses Note from 02/01/2024 to 02/08/2024 indicated there was not a Skilled Daily Nurse's Note assessment completed on 02/02/2024, 02/03/2024, or 02/04/2024. There was no documentation to address the resident's tube feeding and dosing, skin assessment, indwelling Foley catheter care or maintenance, or of the resident's medical or non-medical status with positive or negative changes. Record review of Resident #1's Change in Condition clinical notes dated 02/05/2024 at 1:49 pm, indicated charge nurse, LVN A, was notified by the CNA that she found a wound on the resident's left buttock and some redness to bilateral (both) heels. Record review of Resident #1's Skilled Daily Nurses Note indicated there was not a skilled daily nurses note assessment authored by LVN A, nor a wound assessment completed on 02/05/2024 at 1:49 pm when the resident had a change in condition of a new wound on her left buttock. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/05/2024 at 7:55 pm, authored by RN B, Nurse Summary indicated: the resident received Isosource @ 95ml/hr with water flushes @ 60ml/hr every 3 hours. Moderate sized abdominal hernia visible. The abdominal binder covering the G-tube site was in place. The resident's indwelling urinary Foley catheter was in place. The resident had Podus boots on with no breakdown noted on heels. She had a large deep tissue injury with open skin noted to the top of her left buttock. She had a left upper arm double lumen PICC line the dressing secured. PICC line removed per physician's orders using aseptic technique. Record review of Resident #1's physician's order summary dated 02/26/2024 of all orders, indicated there were orders dated 02/02/2024 for Resident #1 to admit to the facility with orders for NPO, HOB at 45 degrees at all times, and to check G-tube placement, and G-tube feedings, flushes, and residual checks. Record review of Resident #1's physician orders from 02/01/2024 to 02/08/2024 indicated no orders in electronic medical records were found for eternal feeding type or dosing, indwelling Foley catheter care or maintenance, removal of the PICC line and/or new orders for treatment of a new wound identified on 02/5/2024. During an interview on 2/26/2024 at 9:32 am, RN B said she provided care for Resident #1 during the 6 pm to 6 am shift on 02/01/2024 and 02/05/2024. She said she admitted Resident #1 to the facility on [DATE] and she did not recall the resident having any open wounds upon admission. RN B said on 02/05/2024 she received report during shift change that Resident #1 had a new wound on her left buttock. RN B said completed a head-to-toe assessment on Resident #1 and observed a new wound on left buttock, it was the size of a ½ dollar coin and was dark pink/purple area, with thin top layer of skin missing. RN B said she received approval from the physician to discontinue the PICC line on 02/05/2024, but she said she forgot to write the order. RN B said she did not recall if she flushed or maintained the resident's PICC line between 02/01/2024 to 02/05/2024. RN B said on 02/05/2024 she assisted the CNA with repositioning the resident, assisting with care and applying the barrier cream on the resident's buttocks. RN B said an order should have been obtained or written to provide treatment/care to the wound on Resident #1's left buttock. During an interview on 02/26/2024 at 10:20 am, LVN A said she worked 6 am to 6 pm on 02/05/2024 and the aide came to her and told her Resident #1 had a wound on her left buttock. She said assessed the wound to be a reddish/purple area the size of ½ dollar piece. She said she applied barrier cream, notified the ADON for a referral for wound care, and completed an incident report for the new wound. She said she notified the family member who was present in the room about the new wound. She said that she should have completed a skilled assessment note which included a head-to-toe assessment. LVN A said she should have identified the wound and provided a better description and location of the wound, she should have completed a wound assessment sheet, and she should have obtained treatment/orders from the MD. During an interview on 02/22/2024 at 10:20 am, LVN C said she worked 6 am to 6 pm on 02/03/2024 and 02/04/2024 providing care for Resident #1. She said the skilled assessment notes were done daily and during shift change while providing report, the off-going nurse would inform the oncoming nurse which residents needed daily skilled assessments. She said Resident #1's assessment was usually done on the late shift because she was admitted during the late shift. LVN C said therapists worked with the resident during the day shift and the resident required maximum assistance for all care. LVN C said Resident #1 had a DTI on her left buttock and staff were applying barrier cream to the area. LVN C said she recalled flushing the resident's G-tube, caring for the G-tube stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea) site and check tube placement. LVN C said if any changes occurred during the shift, she would document it in the clinical notes section of the electronic medical records. During an interview on 02/26/2024 at 2:45 pm, the DON said her expectation was when new residents were admitted to the facility for skilled therapy, staff should complete a head-to-toe assessment, document all findings in the electronic medical records, and generate orders for all medications and treatments required. The DON said all skilled residents should have a skilled nurse note/assessment completed at least daily. The DON said Resident #1 did not have a skilled nurse note completed on 02/02/2024, 02/03/2024, 02/04/2024, or 02/07/2024 and was transferred to hospital on [DATE]. DON said that the expectation now is that skilled residents have a skilled nurse note/assessment completed each shift, so there is no confusion of who is responsible to complete the assessment. She said Resident #1 was admitted late in the evening on 02/01/2024. She said the ADON should have done a chart review of the new admission and should have noticed there was no order for tube feeding, PICC line care and maintenance, indwelling urinary Foley catheter care and maintenance missing from orders and addressed the issues with RN B. The DON said she in-serviced staff on 02/15/2024 regarding newly admitted residents and the admitting nurse was to complete a head-to-toe assessment of the resident and document in a skilled nurse note and identify any skin abnormalities and document. The DON said inadequate or lacking documentation could put resident at risk for not receiving appropriate care. Record Review of the facility Charting and Documentation policy and procedure, dated 10/11/2021, indicated: Service Standard: All services provided to the resident, progress toward care plan goals, or changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the intradisciplinary team regarding the resident's condition and response to care.1.The following information is to be documented in the resident's medical record: a. objective observations; b. medication administrated c. treatment or services performed; changes in the resident condition; e. events, incidents or accidents involving the resident and f. progress toward or changes in the care plan goals and objectives, 2. Documentation in the medical record will be objective, complete and accurate.5. Per BRS expectations, the clinical record must contain per shift charting of resident's condition for a minimum of 3 days following incident. Record Review of the facility Gastrotomy (G-tube) policy and procedure, revision date of 2/20/2018, indicated: Service Standard: G-tube orders will be written based on each resident's individual needs and will follow current standards for regulatory and best practice guidelines. Procedure: 1. Residents who are admitted to skilled nursing with a G-tube on admission or receive a G-tube after admission will receive physician orders specific to their individual needs. Physician orders should address any specific G-tube care the physician orders, irrigation, specifics about the enteral feeding including formula type method (i.e., pump, bolus), specific about medication administration flush orders including solution type and site care. Any additional needs specific to the G-tube will also be included in the resident's orders. This information should be documented in the residence care plan, and other areas of the clinical records as appropriate. Progress notes and updates will be documented accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of 10 residents reviewed for changes in condition. The facility failed to notify the responsible party (FM F) for Resident #1 when she developed a deep tissue injury on her left buttock that required treatment. The facility failed to notify the responsible party (FM F) for Resident #1 when she was transferred to the local hospital for a change in condition and respiratory distress. The facility failed to notify the responsible party (FM F) for Resident #1 when she had abnormal lab results of RBC of 3.4 (Reference range 4,14-5.8), low Hemoglobin of 8.7 (Reference range 13.0-17.7), and a low Hematocrit of 27.3 (Reference range 37.5-51.0). These failures could place residents at risk for a decline in health, and for family members not knowing the health status of the resident, being informed of and participating in care decisions. Findings included: Record review of face sheet dated 02/21/2024 indicated Resident #1 was admitted on [DATE], was a [AGE] year-old female with diagnoses that included non-traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), non-traumatic intracerebral hemorrhage, intraventricular (the eruption of blood in the cerebral ventricular system), myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles), dysphagia (difficulty or discomfort in swallowing), dementia (loss of cognitive functioning), and weakness to both of her legs. Further review indicated the Emergency Contact #1 was FM F. Record review of Resident #1's initial MDS assessment dated [DATE], revealed section Cognitive patterns - section C500 for BIMS (brief interview of cognitive status) summary score was blank. Review of section C for staff assessment of memory problems indicated the resident had a memory problem and the resident's cognitive skills for decision making were severely impaired. At the time of admission, Resident #1 did not have any pressure injuries. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/01/2024 at 7:30 pm, authored by RN B, the Nurse Summary indicated: Patient here from local hospital post fall/subarachnoid hemorrhage. NPO after failing a swallow study. G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach) in place. Mild redness was noted on buttocks. She had a left upper arm double lumen (two ports) PICC line (thin flexible tubing inserted into a vein in the upper arm threaded into a large vein above the right side of the heart). Record review of Resident #1's Change in Condition clinical notes dated 02/05/2024 at 1:49 pm, indicated the charge nurse, LVN A, was notified by the CNA that she found a wound on the resident's left buttock and some redness to her bilateral (both) heels. The note did not indicate if FM F was notified of the new wound. Record review of Resident #1's incident report dated 02/05/2024 indicated while the resident was getting her brief changed, the aide found a wound on the resident's left buttock. The incident report indicated the resident's Responsible Party was notified, listing FM G as the one notified. The incident report indicated the resident's doctor was notified. LVN A signed the note as the staff who notified the resident's Responsible Party. During an interview on 02/22/2024 at 10:20 am, LVN C said she worked 6 am to 6 pm on 02/08/2024 and when she came on shift at 6 am during her initial rounds Resident #1 was breathing heavy, increased respiratory rate and oxygen saturation (test that measures the amount of oxygen being carried by red blood cells) was 91%, notified on-call doctor and he ordered for her to be sent to local ER for evaluation. LVN C said she notified family but did not recall which family she notified. During an interview and record review on 02/26/2024 at 10:20 am, LVN A said she worked 6 am to 6 pm on 02/05/2024 when the aide told her Resident #1 had a wound on her left buttock. She said she went to resident's room to assess the wound and found an area the size of ½ dollar piece, that was reddish purple. She said she notified the ADON for a referral for wound care and completed an incident report for the new wound. LVN A said she notified FM G who was present in the room when she assessed the new area. She acknowledged she did not review the resident's chart to obtain the assigned representative, she said she assumed it was the FM G in the room. LVN A said she did not notify FM F, Resident #1's assigned representative, of the resident's change in condition. LVN A said that not notifying assigned representative of change in condition could put resident at risk for receiving care and representative aware of resident's condition. Record Review of Resident #1's Skilled Daily Nurse's Note dated 02/05/2024 authored by RN B at 7:55 pm, the Nurse Summary indicated a large deep tissue injury with open skin on top of the left buttock. The note did not indicate if FM F was notified of the wound. During an interview on 2/26/2024 at 9:32 am, RN B said she provided care for Resident #1 during the 6 pm to 6 am shift on 02/01/2024 and 02/05/2024. She said she admitted Resident #1 to the facility on [DATE] and she did not recall the resident having any open wounds upon admission. RN B said on 02/05/2024 she received report during shift change that during shower this AM, Resident #1 was found to have a new wound on her left buttock and was report to doctor. RN B said she completed a head-to-toe assessment of Resident #1 and observed the new wound on her left buttock, it was the size of a ½ dollar coin and was dark pink/purple area, with thin top layer of skin missing, and applied barrier cream. Record review of Resident #1's lab results collected on 02/02/2024 indicated abnormal lab results of RBC (Red Blood Cell count - tells you how many red blood cells you have) 3.4 (Reference range 4,14-5.8), low Hemoglobin (measures the level hemoglobin (a protein in your red blood cells that carries oxygen from your lungs to the rest of your body) in your body) of 8.7 (Reference range 13.0-17.7), low Hematocrit (measures the proportion of red blood cells in the blood - red blood cells carry oxygen throughout the body) of 27.3 (Reference range 37.5-51.0). Record review of Resident #1's clinical notes dated 02/05/2024 authored by the ADON indicated: Received lab results; RBC of 3.4 (Reference range 4,14-5.8), low Hemoglobin of 8.7 (Reference range 13.0-17.7), low Hematocrit of 27.3 (Reference range 37.5-51.0); will fax and call the physician about the above results. There was no indication that Resident #1's representative was notified of the results/findings. Record review of Resident #1's Change in Condition clinical notes dated 02/08/2024 at 6:38 am, authored by LVN C, indicated the physician was notified of Resident #1 experiencing a change in condition with respiratory distress, the on-call physician ordered for Resident #1 to be sent to the ER. Notified Family. The note did not indicate if FM F was notified of the transfer. Record review of Resident #1's hospital records dated 02/15/2024 indicated on 02/08/2024 Resident #1 was seen through the emergency room and later admitted and diagnosed with aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), UTI (infection in part of urinary system), pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), myasthenia gravis (a rare chronic autoimmune disease causing abnormal weakness of certain muscles), and stroke (s loss of blood flow to part of brain, which damages brain tissue). During an interview on 2/22/2024 at 11:59 am, Resident #1's FM F said Resident #1 went to the emergency room on [DATE] with respiratory issues where she was diagnosed with aspiration pneumonia and dehydration. She said the ER physician showed the family wounds and skin impairments. FM F said no one from the facility had called her (assigned representative) to let her know Resident #1 was having any skin issues on 02/05/2024. FM F said someone was typically at the facility every day for Resident #1, but it was usually FM G and he is older and had memory issues, hence why she was the assigned representative. FM F said she was not aware of the wounds or skin impairment until she was shown by the ER physician. FM F said the facility did not notify her of the resident being transferred the local ER on [DATE]. During an interview on 02/26/2024 at 3:20 pm, the DON indicated she did not know Resident #1's representative was not notified of the deep tissue injury on the resident's left buttocks and/or the abnormal lab results on 02/05/2024. The DON said LVN A notified her and the ADON about the deep tissue injury on the resident's left buttocks on 02/05/2024, but she did not realize FM G who was present during the assessment and findings of the wound, was not Resident #1's representative. The DON said facility staff should have verified the resident's representative and the resident representative should have been notified of the wound at the time of the assessment and review of lab results so they would know what was going on and the assigned representative should have been notified of Resident #1's transfer to local ER. Record Review of the facility policy titled Notification of Changes revised date 2/23/2024 indicated: Service Standard: Facility communities - will notify the resident/resident responsible representatives and attending physician of change in the resident's condition or status to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choice about treatment and care preferences. 1. The nurse will immediately notify the resident/resident's responsible representative (consistent with his/her authority) and physician for the following changes (this list is not all inclusive). An accident involving the resident, which results in injury and has the potential for required physician intervention. a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health mental or psychosocial status in their life-threatening condition or clinical complication. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences) or to commence a new form of treatment. Any lab results that fall out of clinical references range into a panic level. Radiology and other diagnostic reports that are significantly outside the clinical reference range and have the potential of needing an immediate alteration to the resident's current treatment plan. A decision to transfer or discharge the resident from the facility. 2. the nurse will notify the resident/resident representative and the resident's physician for non-immediate change of condition in a timely manner. 3. document the notification and record any new orders in the resident's medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #24) reviewed for unnecessary medication. The facility failed to monitor Resident #24 for side effects of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication. Findings include: Record review of Resident #24's face sheet, dated 10/09/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke). Record review of a care plan, initiated 09/13/23, indicated Resident #24 received an anticoagulant medication, Eliquis with interventions which included monitor for bleeding in the urine, nose and stool. Record review of an admission MDS, dated [DATE], indicated Resident #24 had a BIMS score of 15, which indicated intact cognition. Resident #24 had a diagnosis of atrial fibrillation and received an anticoagulant medication 6 of 7 days during the look back period. Record review of the physician orders dated October 2023, indicated Resident #24 was prescribed Eliquis (a blood thinning medication) 2.5 mg two times a day for atrial fibrillation with a start date of 09/09/23. The orders did not address monitoring the anticoagulant medication. Record review of a MAR, dated 10/11/23, indicated Resident #24 received Eliquis 2.5 mg two times a day from 10/01/23 to 10/11/23 with a start date of 09/08/23. Record review of the electronic record for Resident #24 indicated the nurses did not document monitoring of side effects of anticoagulant daily with medication administration. During an interview and record review on 10/11/23 at 12:37 p.m., LVN F said Resident #24 was her patient. She said Resident #24's Eliquis should have been monitored for side effects and was not , it was overlooked. LVN F said the nurses caring for a resident were responsible for adding monitoring to the computer system. She said the ADONs double checked to ensure anticoagulants were monitored. LVN F said it was just overlooked. She said she was educated on monitoring anticoagulants. LVN F said the risk of an anticoagulant not monitored was bleeding. During an interview on 10/11/23 at 12:47 p.m., ADON E said Resident #24 should have been monitored for the side effects of Eliquis. She said the admission nurse was responsible for the addition of monitoring into the system. ADON E said the nurses worked as a team and were all responsible for double checking for medication monitoring. She said it was just overlooked. ADON E said the nurses were educated on monitoring of anticoagulant medication. She said the risk of Eliquis not monitored was a possible bleeding risk. During an interview on 10/11/23 at 12:50 p.m., the DON said Resident #24 should have been monitored for side effects of the anticoagulant medication Eliquis and was not. She said it was overlooked. The DON said the nurses were in-serviced on monitoring anticoagulant medication. She said the admission nurse was responsible for putting the medication monitoring in the computer system when they received the order for the medication. The DON said the ADONs were responsible for double checking within 24 to 72 hours after an order of an anticoagulant medication was placed for monitoring. The DON said she did random checks but had not checked Resident #24's chart. She said the risk of Eliquis not monitored was bleeding. The DON said her expectation was all residents on anticoagulants be monitored . During an interview on 10/11/23 at 1:10 p.m., LVN G said she was the nurse that admitted Resident #24 and completed the admission paperwork. She said she was unaware Resident #24's anticoagulant medication was not being monitored. LVN G said she received education and was aware anticoagulant medication had to be monitored for side effects. She said she had problems putting the medication monitoring in the computer system before and had to get another nurse to help her. LVN G said she should have had another nurse check and make sure the monitoring was put in the system correctly. She said she must have put the medication monitoring in the system incorrectly or overlooked it. LVN G said the risk of not monitoring the anticoagulant/ Eliquis was possible bleeding, bruising and staff being unaware to monitor for bleeding. During an interview on 10/11/23 at 1:20 p.m., the Administrator said the nurses were responsible for monitoring anticoagulants medication. She said the ADONs were responsible for double checking medication for monitoring during the admission process meeting. The Administrator said the interdisciplinary team went over every admission record the morning after or the Monday morning after a weekend. She said her expectation was all anticoagulant medication be monitored. During an interview on 10/11/23 at 3:00 p.m., the Administrator said the facility did not have a specific policy for monitoring anticoagulant medication. Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS® (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop. Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking ELIQUIS: * unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier than normal * bleeding that is severe or you cannot control * red, pink, or brown urine; red or black stools (looks like tar) * coughing up or vomiting blood or vomit that looks like coffee grounds * unexpected pain, swelling, or joint pain * headaches, or feeling dizzy or weak

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 13 residents (Resident #24) reviewed for unnecessary medications. The facility failed to monitor Resident #24 for behaviors or side effects for the antidepressant medication, Lexapro. This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications. Findings include: Record review of Resident #24's face sheet, dated 10/09/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included major depressive disorder (also known as depression is a serious mood disorder that effects how a person thinks feels and handles daily activities) Record review of a care plan, initiated 09/13/23 , indicated Resident #24 received the antidepressant medication Lexapro with interventions which included monitoring for side effects of the medication and record behaviors on the behavior tracking record and observe for changes in mood or behaviors and notify the physician. Record review of an admission MDS, dated [DATE], indicated Resident #24 had a BIMS score of 15, which indicated intact cognition. Resident #24 had a diagnosis of major depressive disorder and received an antidepressant medication 6 of 7 days during the look back period. Record review of the physician orders, dated October 2023, indicated Resident #24 was prescribed Lexapro 20 mg every day for major depressive disorder with a start date of 09/09/2023. Record review of a MAR, dated 10/11/23, indicated Resident #24 received Lexapro 20 mg every day for major depressive disorder from 10/1/23 to 10/11/23 with a start date of 09/08/23, with no monitoring for behaviors or side effects noted. Record review of the electronic medical record for Resident #24 contained no documentation of monitoring for behaviors or side effects of Lexapro from 10/1/23 to 10/11/23. During an interview and record review on 10/11/23 at 12:37 p.m., LVN F said Resident #24 was her patient. She said Resident #24's Lexapro should have been monitored for side effects and behaviors and was not. LVN F said the nurses providing care for a resident were responsible for adding medication monitoring into the computer system. She said the ADONs double checked to ensure antidepressant medication were monitored. LVN F said it was just overlooked. She said she was educated on monitoring antidepressant medication. LVN F said the risk of an anticoagulant not monitored was bleeding. During an interview on 10/11/23 at 12:47 p.m., ADON E said Resident #24 should have been monitored for the side effects of Lexapro but was overlooked. She said the admission nurse was responsible for the addition of medication monitoring into the system. ADON E said the nurses worked as a team and were all responsible for double checking for medication monitoring. She said it was just overlooked. ADON E said the nurses were educated on monitoring of antidepressant medication. She said the risk of Lexapro not monitored was behavior issues if not strong enough and the physician would be unaware if there was a therapeutic range. During an interview on 10/11/23 at 12:50 p.m., the DON said Resident #24 should have been monitored for side effects of the antidepressant medication, Lexapro and was not. She said it was overlooked. The DON said the nurses were in-serviced on monitoring antidepressant medication. She said the admission nurse was responsible for putting the monitoring in the computer system when they received the order for the medication. The DON said the ADONs were responsible for double checking within 24 to 72 hours after the order of an antidepressant medication was placed for monitoring. The DON said she did random checks but had not checked Resident #24's chart. She said the risk of Lexapro not being monitored was a potential of the medication not at a therapeutic dose. The DON said her expectation was all residents on antidepressant medication be monitored. During an interview on 10/11/23 at 1:10 p.m., LVN G said she was the admission nurse for Resident #24 and completed the admission paperwork. She said she was unaware Resident #24's antidepressant medication was not being monitored. LVN G said she received education and was aware antidepressant medication had to be monitored for side effects and behaviors. She said she had problems putting the monitoring in the computer system before and had to get another nurse to help her. LVN G said she should have had another nurse check and make sure the monitoring was put in the system correctly. She said she must have put the monitoring in the system incorrectly or overlooked it. LVN G said the risk of not monitoring the antidepressant was a risk of behavior issues and the medication not being effective. During an interview on 10/11/23 at 1:20 p.m., the Administrator said the nurses were responsible for monitoring antidepressant medication. She said the ADONs were responsible for double checking medication for monitoring during the admission process meeting. The Administrator said the interdisciplinary team went over every admission the morning after or the Monday morning after a weekend. She said her expectation was all antidepressant medication be monitored. Record review of the facility's policy, revised 04/18/23, titled, Psychotropic Drugs indicated: .Psychotropic drugs are those drugs that affect brain activities associated with mental processes and behavior. These drugs include but are not limited to the following categories of drugs: . 2. Anti-depressant; .The facility is expected to attempt a gradual dose reduction in two separate quarters . the first year . attempted annually. A gradual dose reduction is clinically contradicted if: A. Target symptoms returned or worsened after the most recent attempt at a gradual dose reduction and the physician documents the clinical rationale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 1 of 3 residents (Resident #23) and a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #133) reviewed for indwelling catheters. 1. The facility failed to have an appropriate diagnosis for Resident #23's Foley catheter. 2. The facility failed to prevent Resident #133's urinary catheter drainage bag from touching the floor. These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections. Findings include: 1. Record review of Resident #23's face sheet, dated 10/11/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertensive chronic kidney disease (a long-standing kidney condition that develops over time due to persistent or uncontrolled high blood pressure), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), stage 4 pressure ulcer to the right foot (a sore) , and stage 2 pressure ulcer of sacral region (a sore has broken through the top layer of the skin and part of the layer below in the tailbone area). Record review of Wound Assessments, dated 09/18/23, for Resident #23 indicated: * Wound #1-was present on admission, located on right upper arm, and was a 2cm x 1.5cm x 0cm fluid filled intact blister. * Wound #2-was present on admission, pressure wound, located on the pelvic region-sacral area, vascular classification, and was a 1.10cm x 0.8cm stage 2 partial thickness. * Wound #3-was present on admission, pressure wound, located in the pelvic region-coccyx area, vascular classification, and was a 1cm x 1cm x 0cm stage 2 partial thickness. * Wound #4-was present on admission, located on the plantar foot-left heel area, vascular classification, and was a 2cm x 0.3cm x 0.3cm stage 2 partial thickness; and * Wound #5-was present on admission, located on plantar foot-left heel area, vascular classification, 1.5cm x 1.5cm fluid filled blister. Record review of the care plan, dated 09/20/23, indicated Resident #23 was at risk for infection related to indwelling catheter due to multiple wounds. Record review of an admission MDS, dated [DATE], indicated Resident #23 had moderately impaired cognition with a BIMS score of 08 out of 15. She required extensive assistance of 1 person for toileting; she had an indwelling catheter; she had not had a trial of a toileting program; she was not rated for urinary incontinence because she had a catheter; she was at risk of developing pressure ulcers; she had an unhealed pressure ulcers; she had 2 stage 2 pressure ulcer on admission; and she had 1 stage 4 pressure ulcer on admission. Record review of physician orders for October 2023 indicated Resident #23 had an order, dated 10/03/23, for a Foley catheter with related diagnosis of hypertensive chronic kidney disease. Record review of the Wound Evaluation and Management Summary indicated Resident #23 had the following: * 09/20/23-a non-pressure wound to upper arm, a non-pressure wound to the right buttock, a stage 2 pressure ulcer to the sacrum, a stage 2 pressure ulcer to the left foot, and a stage 4 pressure ulcer to the right heel. There was no indication of a stage 3 or 4 to the sacrum. * 09/27/23-a non-pressure wound to the right buttock, a stage 2 pressure ulcer to the sacrum, a stage 2 pressure ulcer to the left foot, and a stage 4 pressure ulcer to the right heel. The non-pressure wound to the right buttock was healed. There was no indication of a stage 3 or 4 to the sacrum. * 10/04/23-all wounds were healed. During an observation on 10/09/23 at 09:37 a.m. revealed Resident #23 was in her bed. She had a Foley catheter. During an observation and interview on 10/09/23 at 11:42 a.m. revealed Resident #23 was in her bed. She had a Foley catheter. Her family member was at the bedside and said the catheter was in place because she had wounds on her bottom. She said the wounds were healed. During an observation on 10/10/23 at 10:41 a.m. revealed Resident #23 was in her bed. She had a Foley catheter. During an observation on 10/11/23 at 11:15 a.m. revealed Resident #23 was in her bed. She had a Foley catheter with yellow sediment in the tubing. During an interview on 10/11/23 at 11:20 a.m., LVN F said Resident #23 had Foley catheter because she had wounds on her bottom. She said the physician was keeping the Foley catheter in place to prevent the wounds on the bottom from getting bad again. She said the wounds that healed were stage 2 pressure wounds. She said she did not realize Resident #23's catheter should have been removed after the 14-day assessment period because it did not meet the criteria for a catheter to be used. During an interview on 10/11/23 11:25 p.m., ADON E said Foley catheters could be retained for stage 3 or 4 pressure wounds to the bottom. She said they should be removed when the wounds healed. She said the indwelling catheters could be used for certain diagnoses and conditions such as urinary retention and neurogenic bladder. She said she did not realize Resident #23 should have had the catheter removed. She said the resident could have discomfort or acquire a urinary tract infection if the catheter were to remain. During an interview on 10/11/23 at 12:14 p.m., the Administrator said the facility did not have a policy, but they followed the federal guideline requirements for Foley catheters. Record review of an email attachment received on 10/11/23 from the MDS Nurse indicated CMS's RAI Version 3.0 Manual, dated 10/2019, 6. Urinary Incontinence and Indwelling Catheter: Use of indwelling catheter (H0100 is checked): (Presence of situation in which catheter use may be appropriate intervention after consideration of risks/benefits and after efforts to avoid catheter use have been unsuccessful with coma, terminal illness, stage 3 or 4 pressure ulcer in area affected by incontinence, need for exact measurement of urine output, and history of inability to void after catheter removal were listed. Surveyor: [NAME], [NAME] 2 . Record review of Resident #133's face sheet, dated 10/11/23, indicated a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Benign Prostatic Hyperplasia (an age-related prostate gland enlargement that can cause urination difficulty). Due to this diagnosis, Resident #133 had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine). Record review of a Baseline Care Plan, dated 10/03/23, indicated Resident #133 had an alteration in bladder elimination and had an indwelling urinary catheter. Record review indicated an admission MDS had not been completed for Resident #133 at the time due to being in process. Record review of physician orders for October 2023 indicated Resident #133 had an order, dated 10/05/23, for an indwelling urinary catheter with related diagnosis of Benign Prostatic Hyperplasia. Record review of a Competency Assessment Catheter Care, Urinary form, dated September 2014, indicated the following. 2b. Be sure the catheter tubing and drainage bag are kept off the floor. During an observation on 10/09/23 at 12:00 p.m., Resident #133 was transported via wheelchair to the dining room for the noon meal by COTA H. The urinary catheter was in a privacy bag below Resident #133's wheelchair with the bag touching the floor as he was wheeled into the room. During a joint interview on 10/09/23 at 12:30 p.m., CNA B and CNA C both said Resident #133â Euro's urinary catheter drainage bag was sitting on the floor. They said they received training on urinary catheter care and the drainage bag should never touch the floor due to risk of infection. During an interview on 10/09/23 at 12:44 p.m., LVN A said Resident #133's urinary drainage bag was on the floor. She said the drainage bag should not be touching the floor. She said in-service and training had been provided in facility in the past. LVN A said potential issues could be infections from contamination of an unclean floor, the urinary drainage bag could potentially be caught on any objects and/or catheter could be pulled out causing harm to residents. LVN A said she monitors the CNAs correct positioning of urinary drainage bags. During an interview on 10/09/23 at 12:45 p.m., ADON D said Resident #133's urinary drainage bag should not touch floor due to risk of infection. During an interview on 10/09/23 at 12:57 p.m., COTA H said she transported Resident #133 from the therapy department to the dining room for the noon meal. She said she was unaware Resident #133's urinary catheter drainage bag had been dragged during transport. She said she had received training in the past regarding urinary catheter care and placement of tubing and drainage bags. During an interview on 10/09/23 at 2:19 p.m., Resident #133 said he wasn't sure why he had a urinary catheter and it was inserted pre-admission while at the hospital. Resident #133 said facility staff positioned the catheter bag below his wheelchair when he was out of bed and in the chair. During an interview on 10/11/23 at 2:00 p.m., the DON/Infection Preventionist said her expectation was for staff to be aware of urinary catheter bag placement to prevent contamination on floors. She said staff were educated on urinary catheter bag placement in the past.

Based on observation, interview, and record review the facility failed to prepare food in accordance with professional standards for one of one kitchen reviewed food service safety, in that: The facility failed to ensure: Culinary specialists A and D [dietary staff] prepared food without facial hair restraint . Approximately 20 pieces of raw boneless chicken breast in the bottom of the sink thawing without cold running water. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: During an observation on 8/16/22 at 10:10 a.m., the culinary specialist A was pureeing the food items and had a light brown full beard which was 1 to 2 inches long and did not have his facial hair restrained. During an observation on 8/16/22 at 10:15 a.m., the culinary specialist D was preparing the steam table with food items. He had an approximately 2-3-inch-wide area and with 1-inch-long curly black facial hair on his chin and the hair was unrestrained. During an observation on 8/16/22 at 10:30 a.m., there were approximately 20 pieces of boneless raw chicken breast in the bottom of the sink along the back wall of the kitchen. The sink had no water running and there were particles of raw chicken mixed in whole pieces and on the inside of the sink. During an observation and interview on 8/16/22 at 10:37 a.m., the culinary specialist A said the chicken in the sink was there if they need more, it would be ready to fry. During an observation and interview on 8/16/22 at 10:38 a.m., the culinary director said this is not the correct way to thaw chicken and surveyor intervened and asked for a temperature of the raw chicken breast. The culinary director checked the chicken temperature and was 69 degrees and he started placing the chicken in the garbage can. He said because it was thawed in an incorrect manner, the chicken could cause food borne illnesses like salmonella. During an interview on 8/16/22 at 10:45 a.m., culinary specialist A said he had heard something about beard restraints and said never heard anything else about them. During an interview on 8/16/22 at 11:00 a.m., the dietary manager and the culinary director said they expected the staff to thaw chicken in the refrigerator or with cold water running over the meat. The culinary director said he had not thought about beards needing to be restrained and said yes hair must be restrained . Review of the policy dated 2010 titled Thawing Food indicated The four Acceptable Methods for Thawing Food. In the refrigerator, at 41 degrees or lower. In a microwave, if food will be cooked immediately after thawing. Submerged under running water, at temperature of 70 degrees or lower. As part of cooking process. Review of the undated policy titled General Guidelines/Expectations For All Team Members indicated . hair restraints must be worn (where appropriate) . The Food Code US food and drug administration obtained from Internet on 8/24/22 indicated . Never thaw food at room temperature, such as on the counter top. There are three safe ways to defrost food: in the refrigerator, in cold water, and in the microwave. Food thawed in cold water or in the microwave should be cooked immediately. The Food Code US food and drug administration date 2017 indicated Hair Restraints .(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. During the exit conference on 8/17/22 at 4:30 p.m., the Administrator was asked for any additional information related to hair/beard restraints and thawing uncooked food, and no additional information was provided