**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents. (Resident #34) The facility failed to develop an accurate care plan for Resident #34 smoking and renal disease. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: Record review of the face sheet dated 02/17/25 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and high blood pressure. Record review of the physician orders dated February 2025 indicated Resident #34 did not have orders to be sent for dialysis (a medical treatment that removes waste and excess fluid when the kidneys are not functioning properly) treatments. Record review of a significant change MDS assessment dated [DATE] indicated Resident #34 was able to understand and was understood. The MDS indicated a BIMS score of 13 indicating Resident #34 was cognitively intact. Resident #34 required a walker to ambulate and supervision for some ADLs. Dialysis was not checked on the form which would have indicated dialysis was being received on admission or during last 14 days. Record review of Resident #34's care plan initiated on 05/03/24 indicated Resident #34 had a diagnosis of renal disease. The resident was at risk for complications related to having a shunt (an artificial passageway allows blood to flow to another area). The interventions included checking the shunt access site dressing after dialysis for uncontrolled bleeding, redness, swelling, and for decreased bruit at the shunt site, notifying the physician of abnormal findings, and to encourage and allow the resident to rest as needed post dialysis, ensure the resident was ready for dialysis on (day), (day), (day), and to remind dietary of need for a to go meal to take with them to dialysis. Record review of Resident #34's care plan was initiated on 01/09/25 indicated the resident smoked cigarettes. The interventions indicated to remind the resident and family that all cigarettes, lighters, matches and smoking paraphernalia must be kept at the nursing station. Remind the resident and family that staff supervision would be provided when not interfering with her care or other residents' care. During an interview and observation on 02/17/25 at 11:45 a.m., Resident #34 said she did not go to dialysis. She pulled her arms out of the covers and said she had no shunts or grafts. During an observation and interview on 02/17/25 at 11:50 a.m., Resident #34 said she had her cigarettes and lighter in her purse and pulled them out of her purse. She asked, Am I breaking the rules? She put the cigarettes and the lighter back into her purse. During an interview on 02/17/25 at 11:55 a.m., the DON said all cigarettes and lighters were kept with the family. During an observation on 02/17/25 at 1:00 p.m., Resident #34 was outside with her family smoking and the family was keeping the cigarettes in his pocket and the lighter was kept by the family. Resident #34 was able to hold her cigarette and did not drop ashes or the cigarette on herself. During an interview on 02/18/25 at 10:54 a.m., the MDS nurse said she was responsible for care plans and MDS assessments. She said the intervention was incorrect on the smoking care plan. She said the interventions for dialysis might have been from 2019 when she was a resident here before. The MDS nurse said the risk of the interventions being incorrect was the resident might not get the proper care and services. She said the next full MDS assessment would include smoking because at the time of the last full assessment Resident #34 was not smoking. During an interview on 02/18/25 at 11:30 a.m. the DON said he wanted the care plans to be correct. He said if the care plans were incorrect the resident might not receive the needed services or might cause confusion. Record review of the undated Comprehensive Care Plans policy indicated Procedures: 1. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being. Procedure: After admission to the facility: 1. Nursing completes the admission Assessment within 24 hours. 2. A Registered Nurse (RN) will review admission Assessment for completion. 3. The RN will then initiate the Care Plan in PCC under the resident clinical chart. 4. Once initiated, the RN will View the Triggered Care Plan Items Now area of the Care Plan (Located in Edit Care Plan area top right corner of screen) 5. RN will review and select appropriate care plans for list or choose to Select All feature then Save Care Plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 16 residents (Resident #34) reviewed for accidents and supervision. The facility failed to ensure that Resident #34 did not have cigarettes and a lighter in her purse and in her room. This failure could place residents at risk for injury, harm, and impairment. Findings included: Record review of the face sheet dated 02/17/25 indicated Resident #34 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and high blood pressure. Record review of a significant change MDS assessment dated [DATE] indicated Resident #34 was able to understand and was understood. The MDS indicated a BIMS score of 13 indicating Resident #34 was cognitively intact. The MDS indicated Resident #34 required use a walker to ambulate and supervision for some ADLs. Record review of the safe smoking assessment dated [DATE] indicated Resident #34 was able to lift cigarettes to her mouth without assistance. She was able to light her own cigarettes. Resident #34 went outside with her family to smoke. Record review of Resident 34's care plan was initiated on 01/09/25 indicated a focus area was the resident smoked. They were advised of the facility smoking policy. The resident required supervision with smoking. Resident #34 smoked outside with family during visits. The interventions indicated to remind the resident and family that all cigarettes, lighters, matches and smoking paraphernalia must be kept at nursing station, and to remind the resident and family that staff supervision would be provided when not interfering with care. During an interview on 02/17/25 at 11:45 a.m. Resident #34 said she smoked with her family outside. During an observation and interview on 02/17/25 at 11:50 a.m., Resident #34 said she had her cigarettes and lighter in her purse and pulled them out of her purse. She asked, Am I breaking the rules? She put the cigarettes and the lighter back into her purse. During an interview on 02/17/25 at 11:55 a.m., the DON said all cigarettes and lighters were kept with the family. He said we do not have a lock box at the nurse's station. The DON said the smoking policy indicated the family was to keep the lighter and cigarettes. During an interview on 02/17/25 at 12:15 a.m., the Administrator said if residents kept the cigarettes and lighters there could be a potential for accidents. He said he was not aware Resident #34 had a lighter and cigarettes in her purse. He said the policy indicated the cigarettes and lighters would be kept with the resident's family. He said the policy was included in the admission packet. The Administrator said the facility did not offer supervised smoking times. He said the family were responsible for bringing cigarettes and allowing their residents to smoke outside during the family visits. Record review of resident smoking-prohibited indicated This facility does not allow smoking by the residents at any time during ones stay. If a resident is found to be smoking or be in possession of any kind related paraphernalia only one warning will be provided .

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary Aide A and Dietary Aide B's hair was completely contained with an effective hair restraint. This failure could place residents at risk of being served unsanitary food and foodborne illness. Findings Included: During an observation in the Kitchen on 02/17/25 at 7:35 a.m., Dietary Aide B had approximately 3-4 inches of hair in the nape (back of her head) and wisps of her hair (around front profile of face) not covered with hair net. She was standing at the prep table preparing drinks (milk, juice). During an observation and interview on 02/17/25 at 7:45 a.m., Dietary Aide B had approximately 3-4 inches of hair on the back of her head and wisps of her hair around her face not covered with a hair net. Dietary Aide B said she Believe she was told to cover whole head with a hair net because hair could get in the food during her training. Dietary Aide B continued to prepare drinks. During an observation and interview on 02/17/2025 at 11:30 a.m., Dietary Aide A walked in the kitchen to the Manager's office passing in front of food being plated by the [NAME] without wearing a hair net. Dietary Aide A said she had only worked at the facility for one month and had been trained to wear a hair net in the kitchen area. Dietary Aide A said she did not have a hair net on because she was just passing by the food on the steamtable. Dietary Aide A said not wearing a hair net could allow hair to get in the food. During an observation on 02/17/2025 at 12:00 p.m., Dietary Aide B had approximately 3-4 inches of hair on the back of her head and wisps of her hair around her face not covered with a hair net. Dietary Aide B was standing in front of food that had been plated by the [NAME] and placed on the prep table for lunch. Dietary Aide B picked up the plate, shook parmesan cheese on the spaghetti, covered it with a lid, placed it on the tray and handed it to a server in the dining room. During an interview on 02/17/2025 at 1:00 p.m., the Dietary Manager stated all staff's hair were to be covered with a hair net when entering the kitchen. She stated she would make sure Dietary Aide B covered her hair completely with no hair hanging in the back or sides of her face and Dietary Aide A was not on duty when she entered the kitchen from the dining room. She stated everyone who entered the kitchen from any door was required to wear a hair net and there were no exceptions. During an interview on 02/19/2025 at 8:30 a.m., the Administrator stated if any staff entered the kitchen, they were expected to wear a hair net. He also stated if a staff's hair was not completely covered, the risk would be food getting in the resident's food, and he had no complaints of food. Record review of facility undated policy titled Dietary and Food Service indicated, Policy: Hair Nets Procedure: It is MANDATORY that All Dietary Staff wear hairnets while on duty in any food preparation area in this facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident's family and responsible party when there was a change in resident condition for 1 (Resident #1) of 3 Residents reviewed for resident rights. The facility failed to inform Resident #1's family when Resident #1 developed pressure ulcer at her coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column) area on 08/05/2024 and had to be seen by the Wound Care Doctor. This noncompliance was identified as PNC. The deficient practice began on 08/05/24 and ended on 08/26/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of their responsible party not being involved in their medical care and treatment. Findings included: Review of Resident #1's face sheet dated 09/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right femur (the longest bone in the human body, it extends from the hip to the knee) , subsequent encounter for closed fracture with routine healing, essential tremor and presence of unspecified artificial knee. Face sheet also reflected Resident #1 had emergency contacts. Review of Resident #1's Nursing Home Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 00, staff assessment indicated both long- and short-term memory problems. The MDS also reflected Resident #1 was at risk for developing pressure ulcer. Review of Resident #1's care plan initiated 08/01/2024 reflected Resident #1 had a communication problem related to cognition, ability to voice wants and needs; resident had potential/actual impairment to skin integrity r/t fragile skin, surgical incision to hip. Review of Resident #1's skin reported dated 08/05/2024 reflected pressure area at her coccyx area. Review of Resident #1's progress notes from 08/05/2024 through 08/24/2024 reflected no area where Resident #'s family was notified of pressure ulcer development or consent from family for Resident #1 to be seen by the Wound Care Doctor. Review of Resident #1's wound doctor's notes reflected Resident #1 was seen by the wound care doctor on 08/15/2024 and 08/21/2024 for pressure ulcer to her coccyx area. Review of Resident #1's progress notes dated 08/24/2024 reflected Resident #1 was transferred to the local hospital. During an interview on 09/12/2024 at 2:16 pm LVN A stated she worked with Resident #1 on 08/05/2024 and that was the day the wound on Resident #1's buttocks was discovered. LVN A stated she was alerted by Resident #1's CNAs and she alerted the DON. LVN A stated she did not notify Resident #1's family because the DON took over the situation and she assumed the DON would have notified the family. LVN A stated after Resident #1 was transferred to the local hospital, the facility's administrator in-serviced staff on Resident's rights and notifying families and RPs of change of conditions. During an interview on 09/12/2024 at 3:16 pm, CNA B stated Resident #1 was admitted to the facility with a bruise at her coccyx area. CNA B stated when the area opened, she notified LVN A and LVN A went to assess Resident #1. CNA B stated she was not sure which date Resident #1's wound at her coccyx opened. During an interview on 09/12/2024 at 3:33 pm CNA C stated Resident #1 had a dark, bruise-like spot at her coccyx area and LVN A was notified when the area opened. CNA C stated she was not sure of the exact date Resident #1's wound at her coccyx opened . During an interview on 09/12/2024 at 3:53 pm the DON stated the first time he saw Resident #1's coccyx area was 08/05/2024 when the wound had opened. The DON stated he was called by LVN A, he went and assessed the wound. The DON stated he swore he called the family to notify them of the wound because he had to get consent for the Wound Doctor to treat the wound. The DON stated he did not document that he called the family or got consent for the Wound Care Doctor to treat. The DON stated if it is not documented, it is not done . The DON stated it was brought to their attention on 08/24/2024 that the family was not aware of Resident #1's pressure ulcer on the coccyx. The DON stated the Administrator conducted an in-serviced on Resident's Rights and family notification for all nurses. During an interview on 09/13/2024 at 10:31 am Resident #1's family stated they were not informed Resident #1 had developed a pressure ulcer. Resident #1's family stated they did not find out Resident # 1 had pressure ulcer until 08/24/2024 when she was being transferred to the local hospital . Resident #1's family stated they were told the wound started to develop on 08/05/2024. Resident #1's family also stated they did not know Resident #1 was being seen by the wound care doctor, they did not sign a consent. During an interview on 09/13/2024 at 1:24 pm the Administrator stated Resident #1's family had called to complain that they were not made aware by the facility that Resident #1 had a pressure ulcer at the coccyx area. The Administrator also stated during the same conversation that someone had called on 08/05/2024 to inform them. The Administrator stated he completed a grievance form, interview staff and conducted training in-serviced on Notification to Physician, family and others; a post test was completed along with the training. Review of facility's in-service dated 08/26/2024 reflected an in-serviced titled Notification to Physician, family and others and was signed by nurses. It was also reflected staff completed a post test. It was also reflected Post test addressed who, when and why notification are made. During an interview on 09/13/2024 at 4:00 pm LVN D stated she was in-serviced on family notification and residents' rights about 2 weeks ago. LVN D stated the family, and the physician should notify of any change in resident's condition like infection, skincare and/or anything that is not normal for the resident. During an interview on 09/13/2024 at 04:09 pm LVN E stated she was in-serviced recently on family notification. LVN E stated families and physician should be notify of falls, medication changes, skin discoloration, and any procedure that may come up for a resident. During an interview on 09/13/2024 at 04:06 pm LVN A stated she was in-serviced on family notification on change of condition. Review of facility's policy titled Resident's Rights undated reflected the following: Purpose .To ensure that resident rights are respected and protected. .To inform residents of their rights and provide an environment in which they can be exercised. To be informed of, and participate in, his or her treatment, including the right to: o Be fully informed in a language they can understand of their total health status o Be informed, in advance, of changes to the plan of care o Be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish the care o Be informed, in advance, by the physician of the risks and benefits of proposed care, of the treatment and alternatives and the right to choose the alternative option they prefer. Review of facility's policy titled Notification to Physician, Family and others undated reflected the following: The facility will remain compliant with reporting guidelines as outlined by state and federal regulations. Notifications of changes --- The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the resident's medical record where applicable, when there is: o A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); o A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to ensure Resident #1 had physician orders for her indwelling foley catheter (is a sterile tube that is inserted into your bladder to drain urine) or for care and monitoring. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. Findings included: Review of Resident #1's face sheet dated 09/12/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right femur (the longest bone in the human body, it extends from the hip to the knee) , subsequent encounter for closed fracture with routine healing, essential tremor and presence of unspecified artificial knee. Review of Resident #1's Nursing Home Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 00, staff assessment indicated both long- and short-term memory problems. Section H (Bladder and Bowel) reflected Resident # 1 had an indwelling catheter. Review of Resident #1's care plan initiated 08/01/2024 and revised 08/08/2024 reflected Resident #1 had an indwelling catheter and at risk for UTI/complications. Care plan interventions included -- assess reports of abnormal urine - sediment, odor, color, amount, etc. report to MD as needed. Empty and record output every shift and PRN, Observe for and document S/S of complications/UTI to include but not limited to: color, consistency, amount of urine, condition of skin at insertion site, pain, burning, discomfort, change in mental status and notify MD of findings, change foley tubing and bag as ordered, check tubing after providing care for kinks, tubing and bag below the level of the bladder reposition as needed, Catheter care per facility policy and PRN, change Foley Catheter every month and as needed. Review of Resident #1's Physician orders from 07/26/2024 through 08/24/2024 reflected no orders for Foley catheter, Foley catheter care, Foley catheter monitoring, Foley catheter output etc. Review of Resident #1's MARs and TARs from 07/26/2024 though 08/24/2024 reflected no evidence of Foley catheter care, Foley catheter monitoring, Foley catheter output etc. Review of Resident #1's progress notes reflected Resident #1 was transferred to the local hospital on [DATE] due to Resident #1 running fever and BP low and family requested Resident #1 be sent to the hospital. During an interview on 09/12/2024 at 2:16 pm LVN A stated Resident #1 had foley catheter throughout her stay in the facility. LVN A stated the CNAs were responsible to provide catheter care, empty the foley catheter and notify the charge nurses of output. LVN A stated the charge nurses were responsible to document foley catheter output. LVN A stated the CNAs always give her Resident #1's Foley catheter output and she did not know where she documented it. During an interview on 09/12/2024 at 3:16 pm, CNA B stated Resident #1 had foley catheter throughout her stay in the facility. During an interview on 09/12/2024 at 3:33 pm CNA C stated Resident #1 had foley catheter throughout her stay in the facility. During an interview on 09/12/2024 at 3:53 pm the DON stated, she had a foley catheter, she came in with a foley catheter. I think it was discontinued at some point and reinserted. There should have been an order for catheter care, output, monitoring. We have to have some way of monitoring; it is high risk for infection. During an interview on 09/13/2024 at 10:31 am Resident #1's family stated Resident #1 had Foley catheter throughout her stay at the facility. Review of the facility's policy titled Catheter Care, indwelling Catheter undated reflected no policy or procedure related to the implementation of physician's orders with regard to the presence of a catheter. It reflected: Basic responsibility -Licensed Nurse, Certified nurse's aide. Purpose-to prevent infection, to reduce irritation. Assessment guidelines: may include, but not limited to: color, consistency, amount of urine, condition of skin at the site of insertion, pain, burning, discomfort Review of facility's Policy titled Physician orders undated reflected: Physician Orders for medications and treatments will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct an initial comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #165) reviewed for resident assessments. The facility failed to ensure Resident #165's admission MDS Assessment accurately reflected her receiving hospice services. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: Record review of Resident #165's face sheet, dated 01/18/24, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included, senile degeneration of the brain (losing the ability to remember, to communicate effectively, and to use reasoning skills to function in their daily lives), dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), hypertension (high blood pressure), and depression (feelings of severe despondency and dejection). Record review of Resident #165's admission MDS assessment dated , 12/28/23, reflected a BIMs score was coded as 9 indicating Resident #165 was moderately cognitively impaired. Record review of section O - special treatments, procedures, and programs O0110. K1. Hospice care revealed Resident #165 was coded N/A and No for receiving hospice services. Record review of Resident #165's clinical physician orders dated on admission, reflected Resident #165 was admitted to the facility under the care of hospice services. Record review of Resident #165's care plan dated 01/08/24 reflected Resident/family had elected hospice care for senile degeneration of the brain. Resident was at risk of complications related to dying process (weight loss, skin breakdown, dehydration, placement of indwelling catheter, fecal impactions, or gradual or rapid loss of the ability to move.) Goals: Resident and family's wishes would be honored through next review date; Resident would be kept as comfortable as possible through next review date. Interventions: Coordinate care with Hospice team. Hospice team to visit and perform care per schedule; Encourage and provide assistance to turn and reposition q 2 hours in PRN comfort; If transferring resident notify receiving facility of election of hospice and code status; Notify Hospice of resident and family request for Clergy support/visit, questions about dying process; Notify MD, Hospice of S/S of infection, injury and implement appropriate interventions within code status, Observe for S/S of impending death to include but not limited to: change in mental status, non-responsive, change in breathing pattern, change in heart rate, cyanosis (the change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed), mottling to extremities , decreased bowel sounds, increased lung sounds; Notify Hospice, RP, MD of change. In an observation on 01/17/24 at 11:39 AM Resident #165 was lying in bed, moaning at times, unresponsive to verbal stimuli, not able to answer questions. Resident #165 appeared clean and showed no signs of pain or distress. Resident #165's family was at bedside. Resident #165 had blankets pulled to chest area with call light in reach. In an interview on 01/17/24 at 11:46 AM with Resident #165's FM she stated things had been ok with the care of Resident #165 and Resident #165 had been residing in the facility since December 21st. She stated she had no concerns with anything right now. She stated Resident #165 was on the downhill and nothing could be done. She stated Resident #165 was on Hospice care and she had no concerns with hospice. She stated Resident #165 recognized the hospice nurse when she came in. In an interview on 01/19/24 at 9:03 AM with the MDS nurse, she stated she was responsible for completing all MDS assessments. She stated Resident #165 was a new admission and Resident #165 admitted under hospice services. She stated that Resident #165's admission MDS assessment was miscoded and that she needed to correct it. She stated she had been trained on how to complete the MDS assessments and she did not believe there was any effects that could have been caused from the MDS assessment being coded incorrectly. She stated Resident #165 was private pay and if Resident #165 would have been on MCR or MCD, it may have affected Resident #165 or the facility differently in a financial way. In an interview on 01/19/24 at 9:37 AM with the ADM, he stated if a resident was on hospice services it should be coded as yes on the MDS assessment. He stated hospice not being coded on the MDS assessment would not affect the care provided for the residents. He stated he did not feel there would not be any issues if hospice was not coded on the MDS assessment. He stated he was made aware that Resident #165's MDS assessment was coded incorrectly, and they were going to perform an audit of all MDS's. He stated the MDS nurse was responsible for completing the MDS assessment and had been working in the facility for about two years. He stated the MDS nurse had been trained on how to complete an MDS properly and that the MDS nurse is an RN and should be ensuring the accuracy of the MDS assessments. In an interview on 01/19/24 at 11:08 AM with the DON, he stated the MDS nurse was responsible for completing MDS assessments and she had been trained on completing the MDS's correctly. He stated they had a corporate nurse that ensured the accuracy of the MDS assessments. He stated the MDS assessments should reflect if a resident was admitted on or was receiving hospice care. He stated if an MDS assessment was completed incorrectly, someone may not know if a resident was on hospice services. Record review of facility MDS 3.0 user's manual dated October 2023: CMS's RAI Version 3.0 Manual; page O-7, O01 10K1, Hospice care - Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of five residents reviewed (Resident #1, #2, and #3) for respiratory care. 1. The facility failed to ensure Resident #1's humidifier for the oxygen concentrator had water. 2. The facility failed to ensure Resident #1's nebulizer mask was bagged while not in use. 3. The facility failed to ensure Resident #2's oxygen tubing was changed weekly as ordered. 4. The facility failed to ensure Resident #3 had an oxygen sign posted outside her bedroom. These deficient practices could place residents at risk for inadequate care and respiratory infection. Findings include: 1. Record review of Resident #1's face sheet, dated 11/17/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included presence of unspecified artificial knee joint, Osteoarthritis (tissues in the joint break down over time), Hypertension, Heart failure, Hyperlipidemia (high fat level in blood), Localized Edema, Abnormal weight loss, Atrial fibrillation (irregular heart rhythm), Anemia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (problems that cause breathing difficulty), Dementia, Psychotic Disturbance, Mood disturbance and Anxiety. Record review of Resident #1's quarterly MDS assessment, dated 09/19/23, reflected a BIMS of 8, which indicated her cognition was moderately impaired. Section O (Special Treatments, Procedures, and Programs) reflected she received respiratory therapy 7 days a week. Record review of Resident #1's quarterly care plan, revised 09/20/23, reflected: Resident is at risk for shortness of breath, respiratory distress, increased anxiety due to Dx COPD. and the relevant interventions were: Provide O2 as ordered and indicated .Provide NEB/inhalers as ordered. Record review of Resident #1's physician order, dated 09/07/23, reflected: 1.O2 via Nasal Cannula: Titrate O2 2-5 LPM to keep SPO2 equal or greater than 92%. Write liters per min of O2 or Room Air. Check Q Shift. 2.Change out nebulizer mask and tubing weekly. Nursing to date and initial on plastic bag and equipment to be stored in bag when not in use. 3.Check face mask and tubing weekly. May replace if appears soiled or known contamination. Replace personal bag at bedside for items when not in use. Observation and interview on 11/17/23 at 10:00 AM revealed Resident #1 was laying in her bed. She was getting oxygen from the oxygen concentrator via tubing. The water bottle attached to the concentrator, dated 10/23/23, was empty. Resident #1 reported that it was for a while the staff had changed the tubing. She stated she did not remember the exact day when they changed the tubing. Observation on 11/17/23 at 10:05 AM revealed, on Resident #1's bed side table the nebulizer mask was placed unbagged, with the inside of the mask facing down. 2. Record review of Resident #2's face sheet, dated 11/17/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Hyperlipidemia, Osteoarthritis (tissues in the joint break down over time), Hypertension, Muscle wasting, Abnormalities of gait and mobility, Cognitive communication deficit, Dysphagia (Difficulty to swallow), Dementia, Behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety and Major depressive disorder. Record review of Resident #2's quarterly MDS assessment, dated 10/24/23, reflected the resident was unable to complete the interview. Section O (Special Treatments, Procedures, and Programs) reflected she was on oxygen therapy. Record review of Resident #2's quarterly care plan, revised 11/12/23, reflected: The resident has Oxygen Therapy r/t SOB. and the relevant intervention was: Oxygen settings: The resident has O2 via nasal prongs/mask @ 2L continuously. Record review of Resident #2's physician order, dated 09/07/23, reflected: 1. Change O2 tubing, humidifier bottle, and bag to place tubing in every Saturday night shift. If resident hasO2 tank on WC, place a separate bag on WC for NC. Cleanse concentrator filter. May replace as needed. 2. Titrate O2 to keep SPO2 greater than or equal to 90%. Check O2 sats every shift. Observation on 11/17/23 at 12:00 PM revealed Resident #2 was not in her room. The nasal cannula was connected to the oxygen concentrator and was dated 10/29/23. There was no humidifier attached to the tubing. The facility did not change the humidifier and oxygen tubing every Saturday as ordered by the physician 3. Record review of Resident #3's face sheet, dated 11/17/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Radiculopathy (pinched nerve), Edema (Swelling), Atrial Fibrillation (Irregular Heartbeat), Sciatica (pain, weakness, numbness, or tingling in the leg), Low back pain and Seasonal allergy. Record review of Resident #3's initial MDS assessment, dated 11/08/23, reflected her BIMS score was 13, which indicated she was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected she was on oxygen therapy. Record review of Resident #3's initial care plan, dated 11/12/23, reflected: The resident has Oxygen Therapy r/t SOB. and there were no interventions listed. Record review of Resident #3's physician order, dated 11/02/23, reflected: 1. O2 via Nasal Cannula: Titrate O2 2-5LPM to keep SPO2 equal or greater than 90%. Write liters per min of O2 or Room Air. Check Q Shift. 2. Check O2 tubing, humidifier water, and filter weekly on night shift. May replace if appears soiled or known contamination. Cleanse concentrator filter. Replace personal bag at bedside for items when not in use. If resident has O2 tank on walker, Place separate bag on WC for items. Observation on 11/17/23 at 12:00 PM revealed Resident #3 was in her room in a wheelchair. There was no sign posted outside her bedroom which stated she was on oxygen usage. During an interview on 10/17/23 at 1:47 PM, the DON stated his expectations were that oxygen tubing, mask and humidifier were replaced weekly though the policy stated change them when contaminated or visibly soiled. He stated the nurses were responsible for ensuring the tubing was changed weekly. The DON said the importance of changing the oxygen tubing regularly was to ensure the tubing was providing adequate oxygen, there were no kinks in the tubing, and to prevent respiratory infections through contamination. The DON stated the risk of not having the oxygen sign posted was the risk of fire due to the high flammability of oxygen and everyone was responsible for ensuring the oxygen signs were posted. Record review of the facility's, undated, policy Oxygen Administration reflected: .5. Prefilled, scaled, disposable humidifiers may be changed per facility procedure. . 8. precaution: constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration. 9. Check and clean oxygen equipment (including filter), masks, tubing and cannula, if visibly spiled or otherwise known to be contaminated, replace masks, tubing and/or cannula. Regular replacement intervals are not required, but nor otherwise prohibited.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for dietary services. 1.The facility failed to ensure expired meat and cheese were discarded appropriately. 2.The facility failed to ensure cheese in the kitchen was dated and labeled appropriately. These failures could place residents at risk for food contamination and food-borne illness. Findings include: During an observation on 11/17/2023 at 12:15 PM in the walk-in refrigerator revealed, the following items: 1. One plastic bag contained a chunk of pork loin with open date of 11/04/23 and used by date of 11/07/23. 2. One block of cream cheese with an open date of 10/11/23 and a used by date of 10/20/23. 3. One block of cream cheese dated 10/20/23. There was no 'Use by date documented. 4.One plastic bag contained cheese slices dated 10/29/23. There was no Use by date documented. 5. One plastic bag contained shredded cheese dated 10/31/23. There was no Use by documented. During an interview on 11/17/23 at 1:00 PM with the DM, she stated food items kept in a refrigerator should be consumed within 7 days once they were opened or removed from the freezer for thawing. She stated consumption of expired meat could cause food borne diseases. The DM stated storing food products in the appropriate storage area in a sealed packet with the name, open and used by dates on it was necessary to know whether they were usable or not. She stated outdated food could cross contaminate other food. She stated it was her responsibility to ensure all the food items in the kitchen were within the expiry date. During an interview on 11/17/23 at 1:30 PM with the ADM, he stated He stated improper food handling caused food borne diseases and the staff in the kitchen needed further training related to food storage and handling. Record review reflected there were no trainings on food storage and handling from 07/01/23. Record review of the facility's, undated, policy titled, Food Cooks reflected: .Provide food that is free from contamination thus risking the health and wellbeing of the residents and staff. Comply with Department of Health Guidelines in the food service department. Procedure: All staff will be aware of proper food handling and storage procedures . Open packages of food are stored in closed containers with tight covers and dated as to when opened . All containers must be labeled with the contents and date food item was placed in storage. Previously cooked foods can be held in refrigeration of 41 degrees F [Fahrenheit] or lower for up to 7 days and then must be discarded .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of 5 (Resident #1) residents reviewed for pressure ulcers. The facility failed to ensure Resident # 1, who transferred from another facility with a pre-existing pressure ulcer, received an initial assessment and a 48-hour initial care plan. The facility failed to ensure Resident #1 received an order for the treatment of a pre-existing pressure ulcers upon admission. The facility failed to ensure Resident #1's pressure ulcer was measured at the initial skin assessment. The facility failed, for the first 4 days of Resident #1's admission at the facility, to administer treatment for her pressure ulcer. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #1's Face Sheet dated 10/23/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses type 2 diabetes mellitus with foot ulcer and acute systolic (congestive) heart failure. Review of Resident #1's initial MDS dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 entered the facility from another nursing home. Resident #1 had an active diagnosis of medically complex conditions. Resident #1 was a tobacco user. Resident #1 had an infection of the foot, a diabetic foot ulcer. Review of Resident #1's Comprehensive Care Plan reflected a focus area initiated on 10/11/2023 - Resident #1 has a diabetic Ulcer related to diabetes, poor circulation, non-compliance with diabetic diet. Resident #1 had Care Plan intervention/tasks initiated 10/11/2023 listing - 1. Carefully dry between toes but do not apply lotion between toes. 2. Determine and treat cause: Poor fitting shoes, blood sugar control, pressure area, infection. 3. Ensure appropriate protective devices are applied to affected areas. 4. Monitor pressure areas for color, sensation, temperature. 5. Monitor/document wound size, depth, margins: document progress and wound healing on an ongoing basis. Notify MD as indicated. 6. Monitor/document/report to MD signs and symptoms of infection: green drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, fever. 7. Monitor/document/report to MD as needed changes in wound color, temp, sensation, pain, or presence of drainage or odor. 8. Petal space pulses with leg and foot ulcers. 9. Physician resident of affected area. Change position every two hours and PRN. 10. Refer to foot care nurse/podiatrist. 11. Treat wounds as per facility protocol. Review of Resident #1's previous facility orders dated 08/30/23 reflected order to cleanse open area to L heel and apply calcium alginate (calcium alginate used for entrapment of enzymes and forming artificial seeds in plant tissue culture) to wound bed and cover with dry protective dressing each day shift. Review of Resident #1's admission Skin assessment dated [DATE] reflected pressure ulcer on L heel no length, width, depth, or stage documented . Review of Resident #1's facility order audit report dated 10/23/23 reflected on 09/24/23 an order was placed for wound care: apply Calcium Alginate (calcium alginate used for entrapment of enzymes and forming artificial seeds in plant tissue culture) to wound bed, cover with heel cup and wrap with stretch gauze. Skin prep entire heal everyday shift for weight loss for 30 days. Review of Resident #1's MAR reflected wound care treatment for order began on 09/25/23. Interview with the DON 10/23/23 at 2:44 pm, revealed he was responsible for resident initial care plan or 48-hour care plan prepared for Resident #1. The DON revealed he just forgot to do it. He revealed it is important to do a resident care plan to make sure that all staff members know what is needed for the resident and for the residents to get the care they need. The DON revealed that it is the facility's policy to conduct an initial resident assessment and baseline care plan within 48 hours of the resident entering the facility. The DON was unaware that Resident #1 did not receive an order for treatment for her pressure ulcer until 3 days after her admission to the facility and treatment did not begin until 4 days after her admission to the facility. The DON revealed that if pressure ulcers are not care planned and go untreated, they could get worse, become infected, could become septic and the resident could be in pain. Interview on 10/23/23 with the ADON at 2:33 pm, revealed that it is facility policy that residents receive a skin assessment within 24 hours of entering the facility and the type of dimension, and stage of the pressure is documented. She revealed that if pressure ulcers are not treated, they could become septic and there is a danger of death. Interview on 10/23/23 with the wound care doctor at 3:01 pm, revealed the first time saw Resident #1 for wound care was on 09/26/23 and that her pressure ulcer was present prior to Resident #1's admission to the facility. The wound care doctor revealed Resident #1 was a high risk for pressure ulcers complications because she had diabetes and was a smoker. The wound care doctor revealed that these are the 2 highest risk factors involving pressure ulcer condition. He revealed it is important for the facility to assess residents upon admission because it is important to know what type of wound you are handling. Non treatment of a pressure ulcer with a diabetic resident condition could cause the wound to worsen and get infected could lead the overall progression of the disease . Interview on 10/23/23 with the ADM at 3:34 pm, revealed it was the policy of the facility that a in initial assessment upon admission and baseline care plan and skin assessment be performed on every resident within 48 hours of the resident's admission into the facility. Review of facility skin assessment policy undated reflected the facility is to provide a routine schedule of assessments for each resident skin assessment and ensure prompt identification and treatment for noted skin concerns. Assess the resident head to toe to identify all skin concerns to include but not limited to pressure ulcers of any type. For new skin concerns or worsening conditions notify the director of nurses, medical doctor, and family of any new skin concerns to include pressure ulcers. Implement appropriate treatments, interventions protocols or obtained appropriate treatment orders. Review of facility at baseline care plan policy undated revealed objectives: to ensure uniformity of concern approached by nursing home and team members. To help resident and their families be part of a team approach in ensuring residents needs and assessing with problems period to clearly delineate instructions and needed to provide effective and in person centered care of their resident that meet professional standards of quality care. Review of facility baseline care plan undated revealed nursing home staff will develop a baseline care plan for the resident's care within 48 hours of admission to the facility. The baseline care plan will include, at minimum, the following: initial goals based on admission orders and physician orders. Review of facility Preventing Pressure Ulcers Repositioning to Prevent and Treat Heel Pressure Ulcers policy undated revealed: inspect the heels at least daily.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen where all facility food was prepared. The facility failed to ensure the expired ground meat in the refrigerator in the kitchen was discarded appropriately. The facility failed to ensure the dented food can in the dry storage in the kitchen was discarded appropriately The facility failed to ensure the hotdog buns in the kitchen were dated, labeled, sealed, and stored appropriately. These failures could place residents at risk for food contamination and food-borne illness. Findings included: During an observation on 03/28/23 at 11:15 am in the kitchen the following items were found: 1.One packet of ground beef weighing 5 pounds at the bottom shelf of the refrigerator. The meat was very soft to touch and slightly dark in color. The date of removal from the freezer written on it was 03/19/23. 2.One can of 'sloppy joe sauce' weighing 6 pounds with a dent measuring 1.5-inch D x 2-inch W x 3- inch L, stored in the dry storage area. 3.One plastic bag containing 8 hotdog buns on the countertop at the back of the kitchen among various utensils and containers. The bag was not sealed and dated. During an interview on 03/28/23 at 11.30am with DMC, she stated she was the cook and in charge of the kitchen activities that day in the absence of DM. She stated the ground meat should not have been there or in the refrigerator as it was old for consumption. When the investigator asked what the facility policy about meat products, DMC said she was not sure about the facility policy however knew that meat kept in a refrigerator should be consumed within 7 days once it was removed from the freezer for thawing. She stated consumption of expired meat could cause food borne diseases. DMC stated food products in dented cans should not be used for cooking. When the investigator asked what the consequence was of using food item in dented cans, DMC said she did not know the reason. DMC stated storing food products in the appropriate storage area in a sealed packet with name and date on it was necessary to know whether they were usable or not. During an interview on 03/28/23 at 11.45am when the investigator asked DA A why the food items in a dent can should not be used, DA A stated she did not know the reason however knew dented cans should be returned to the supplier. When investigator asked what the shelf life of meat in a refrigerator after removed from a freezer for thawing, DA A stated she did not know. DA A stated all the food items stored should be labeled and sealed properly. During an interview on 03/28/23 at 1:30pm with ADM stated it was unfortunate that there were deficiencies in food handling in the kitchen. He stated improper food handling causes food borne diseases and the staff in the kitchen needed further training related to food storage and handling. Record review on 03/28/23 reflected there were no training on food storage and handling in the last three months. Record review on 3/28/23 of the facility policy titled, Food Cooks Senior Care LLC not dated reflected: .Provide food that is free from contamination thus risking the health and wellbeing of the residents and staff. Comply with Department of Health Guidelines in the food service department. Procedure: All staff will be aware of proper food handling and storage procedures . . Food will be served in such a way as to prevent growth of bacteria . . Open packages of food are stored in closed containers with tight covers and dated as to when opened . . All containers must be labeled with the contents and date food item was placed in storage. Previously cooked foods can be held in refrigeration of 41 degrees F [Fahrenheit] or lower for up to 7 days and then must be discarded . Record review on 04/02/2023 of U.S. Department of Agriculture website https://ask.usda.gov/s/article/Is-it-safe-to-use-food-from-dented-cans dated 03/23/2023 reflected: If a can containing food has small dent but is otherwise in good shape, the food should be safe to eat. Discard deeply dented cans. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with deep dent on any seam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 5 (Resident #27, Resident #34, Resident #36, Resident #44, Resident #54) of 6 residents reviewed for care plans. 1. The facility failed to develop a care plan with use and warnings of anti-anxiety and depression medications for Resident #27 and Resident #54. 2. The facility failed to develop a care plan that properly identified Resident #34 and Resident #54's advance directives. 3. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #36, and Resident #54's hospice services. 4. The facility failed to update Resident #54's care plan to address changes in diet texture. 5. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #54's use and warnings of narcotics. 6. The facility failed to develop a care plan with measurable objectives and timeframes for Resident #44. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: 1.Review of Resident #27's face sheet, dated 10/27/22, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Major depressive disorder, anxiety disorder, Alzheimer's disease, Review of Resident #27's MDS assessment, dated 09/09/22, revealed her BIMS was 3 (severe cognitive impairment). Her active diagnoses included: Alzheimer's Disease, anxiety, and depression. Review of Resident #27's Orders Summary Report dated 10/27/22, revealed the following orders: -Escitalopram Ozalate Tablet 5MG, Give 1 tablet by mouth one time a day for depression, dated 12/23/21, by prescriber. -Alprazolam Tablet 0.5 MG, Give 1 tablet by mouth three times a day for anxiety, dated 06/28/22, by prescriber. -Side Effects to antianxiety medication, monitor day and night shift, dated 08/02/22, by prescriber. -Side effects to antidepressant medications, monitor day and night shift, dated 08/02/22, by prescriber. Review of Resident #27's care plan dated 09/06/22, did not reflect Resident #27's use of anti-depression or anxiety medication or monitoring for side effects. 2.Review of Resident #34's face sheet, dated 10/27/22, revealed, he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: encephalopathy (disease of the brain), cerebral infarction (stroke), depression, and seizures. Review of Resident #34's MDS assessment, dated 08/22/22, revealed, his BIMS was 4 (severe cognitive impairment). His active diagnoses included: Cerebrovascular accident (stroke), seizure disorder, malnutrition, encephalopathy (disease of the brain), and depression. Review of Resident #34's Orders Summary Report, dated 10/27/22, did not reveal advance directive orders. Review of Resident #34's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form, dated and signed by responsible party on 09/27/21, revealed Resident #34's advance directive wish was do not resuscitate. Review of Resident #34's care plan, dated 08/17/22, reflected Resident #34's advance directive of Full Code initiated on 04/20/21. 3.Review of Resident #36's face sheet dated 10/27/22, revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: cerebrovascular disease (condition that affected blood flow and vessels in the brain), adult failure to thrive, depression, anxiety, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident #36's MDS assessment. dated 09/12/22, revealed his BIMS was 3 (severe cognitive impairment). His active diagnoses: Hypertension (high blood pressure), hyperlipidemia (high cholesterol), malnutrition, anxiety disorder, depression, and cerebrovascular disease. His active special treatment: Hospice care. Review of Resident #36's Order Summary Report dated 10/27/22, revealed the following orders: -Admit to Oaks Nursing Care (ONC) under the care of [Hospice Company], dated 09/03/22, by prescriber. -DNR, dated 09/03/22, by prescriber. Review of Resident #36's care plan dated 09/26/22, revealed no focus area, goal, or interventions for hospice care. 4.Review of Resident #44's face sheet, dated 10/27/22, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: nontraumatic intracerebral hemorrhage in hemisphere, subcortical (stroke), chronic obstructive pulmonary disease (lung disorder), hyperlipidemia (high cholesterol), and Type 2 diabetes mellitus with other diabetic neurological complications. Review of Resident #44's MDS assessment, dated 10/03/22, revealed his BIMS was 15 (cognitively intact). His active diagnoses included: diabetes mellitus, hyperlipidemia (high cholesterol), cerebrovascular accident (stroke), malnutrition, and chronic obstructive pulmonary disease. Review of Resident #44's clinical record revealed no evidence of a care plan completed. 5.Review of Resident #54's face sheet, dated 10/27/22, revealed he was an [AGE] year-old male who was originally admitted to the facility on [DATE]. His diagnoses included: pneumonia, weakness, hypertension (high blood pressure), anxiety, hypokalemia (low potassium level), and acute respiratory failure. Review of Resident #54's MDS assessment, dated 10/03/22, revealed his BIMS was 10 (moderate cognitive impairment). His active diagnoses included: hypertension (high blood pressure), malnutrition, anxiety, respiratory failure, hypokalemia (low potassium level), weakness. His active special treatment: Hospice care. Review of Resident #54's Order Summary Report dated 10/27/22, revealed the following orders: -Regular Diet: Mechanical soft texture, honey consistency, for swallowing issues, dated 10/14/22, by prescriber (verbal). -DNR, dated 10/03/22, by prescriber (written). -Morphine Sulfate (concentrate) solution 20 MG/ML, give 0.25 ml by mouth every 2 hours as needed for pain; shortness of breath, wheezing, dated 09/30/22, by prescriber (written). -Lorazepam Tablet 1 MG, Give 1 tablet by mouth every 4 hours as needed for anxiety or agitation. -Norco Tablet 5-325 MG (Hydrocodone-acetaminophen) Give 2 tablets by mouth every 6 hours as needed for pain, not to exceed 3 Grams of Acetaminophen in 24 hours. Resident #54's Order Summary Report did not have hospice services identified. Review of Resident #54's written orders in electronic health record system revealed a scanned copy of an order stated: Admit [Resident #54] to [hospice company], dated 09/28/22. Review of Resident #54's care plan, dated 09/28/22, revealed the following: - Focus: At risk for/history of weight changes and malnutrition to: protein calorie malnutrition, dated initiated: 07/28/22. - Intervention: Regular Diet, Mechanical soft texture, thin liquids dated 08/03/22. Resident #54's care plan inaccurately identified advance directive of Full Code dated 07/28/22 as there was an active DNR order dated 10/03/22. Resident #54's care plan did not have a focus, goal, or intervention/tasks for hospice services, narcotic medication, or anxiety medications. An interview on 10/27/22 at 12:49 PM with the DON revealed he worked for the facility since 2014. The DON stated initially the care plans were the responsibility of the MDS Coordinator. However, the facility had been without an MDS Coordinator for about a month. The DON stated the Director of Clinical Reimbursement (DCR/Corporate) was coming two times a week to ensure MDS assessments and care plans were maintained. The DON stated, during the time of not having an MDS nurse, he or the DCR were responsible for care plans. The DON stated if a resident went on hospice, he would create the referral and then when the family or resident agreed to hospice services, the hospice company provided him the paperwork and it was his responsibility to put the order into the system and update the care plan. The DON stated if the information was not in the care plan or electronic orders, the nurses could refer back to a paper chart. However, the DON reviewed Resident #54's paper chart, and there was no order present. The DON stated he was not sure what happened, but it appeared this slipped through the cracks. The DON stated the risk of not showing hospice orders, or any other individualized area, the nurses would not know the residents were on hospice, or who to notify or how to properly care for the residents. The DON stated a resident's diet, use of narcotics, anti-anxiety or depression medications, should be in the care plan. The DON stated again the risk of not having these areas on the care plan puts the residents at risk for not getting the services they deserve. The DON stated no one ultimately reviewed his work, he was trusted to input information accurately. An interview on 10/27/22 at 2:04 PM with the Administrator revealed he worked at the facility since August 2022. The Administrator stated he did not attend care plan meetings as a rule, but if there was a particular concern or need, he would be in attendance. The Administrator stated he did not input care plans. He relied on the DON and/or MDS Coordinator to input and update care plans as needed. The Administrator stated their past MDS Coordinator went back to being a floor nurse about a month ago as she was burnt out from completing MDS assessments and the lack of attention to detail was observed. The Administrator stated while they did not have an MDS Coordinator the facility relied on the Director of Clinical Reimbursement (DCR) and the DON to update and input care plans. The Administrator stated it was important to have accurate, individualized care plans for the residents because it tells the story of the resident. The Administrator stated if the care plans were not accurate, the resident was at risk for not receiving the individualized care they deserve. The Administrator stated, previously he knew there was an issue regarding accurate care plans, but thought the facility had resolved this deficiency. The Administrator stated he ultimately was responsible for all things in the building but to ensure the accuracy of care plans would fall on his DON. An interview on 10/27/22 at 2:23 PM with MDS Coordinator, revealed she was an RN and worked for the facility as a floor nurse since 2016; however, she was not hired for this position until 10/06/22, and she was still learning her position as she has never input an MDS. MDS C stated she could not speak to the accuracy of care plans prior to this date but would recommend the surveyors contact the DCR as she was training her for this position and completed care plans during the time of not having an MDS Coordinator. An interview on 10/27/22 at 2:25 PM with the DCR revealed she was an LVN and worked for the facility for over 13 years and was promoted to Director of Clinical Reimbursement about 1.5 years ago. The DCR stated she filled in as the MDS C at the facility from the first part of September until the new MDS C was hired on 10/06/222. The DCR stated she was still very involved in care plans and MDS assessments as the new MDS Coordinator had no experience. The DCR stated she would physically be at the facility two times a week for resident/family interviews and would continue to work on the care plans and MDS when she was not assisting her other facilities. The DCR stated when she began reviewing the care plans in September she saw a deficiency and she continued to try to get the care plans caught up. The DCR stated care plans should include all areas listed in the MDS to include, hospice, diet, ultimately anything that required a physician's order. The DCR stated care plans were important because that was how the staff knew how to care for the residents. The DCR stated if the care plans were not accurate the staff could not meet the needs of the residents appropriately or in a timely manner. Review of facility policy titled: Comprehensive Care Plans, undated, revealed the following: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being, b. Any services that would otherwise be required but are not provided due to a resident exercising their right to refuse treatment and services . 3. The comprehensive care plan will be: a. Developed within 7 days after completion of the comprehensive assessment unless the comprehensive care plan will be used as the baseline care plan which requires completion within 48 hours of admission to the facility (See Baseline Care Plan Policy) .