**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #21) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan based on the assessed needs with measurable objectives and timeframes in area of colostomy for Resident #21. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #21 Review of Resident #21's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: colostomy (opening in the abdominal wall to allow the colon to pass waste), brain bleed, and kidney disease. Review of Resident #21's MDS dated [DATE] revealed: BIMS of 13 which indicated no cognitive impairment. Review of section H revealed the resident had a colostomy. Review of Resident #21's Comprehensive Care Plan, initiated 04/21/2025, revealed no evidence of the colostomy. Review of Resident #21's electronic physician's orders revealed: Clean area around stoma (opening in the abdominal wall to allow the colon to pass waste)with soap and water, pat dry, apply skin prep with wafer and bag, Empty colostomy bag every shift, and Colostomy care every shift. Observation and interview on 08/19/25 at 11:41 AM, revealed Resident #21 up in bed, and his colostomy bag in place. He stated that he did not maintain his colostomy bag and that the care was provided by facility staff. During an interview on 08/20/2025 at 11:13 AM, the DON stated that she was responsible for care plans. She stated all care plans had been updated and transferred over from the old computer system to the new one. She stated all things related to the resident's care and preferences should have been on the resident's care plan. The DON stated that Resident #21's colostomy and how to care for it should have been care planned. She stated not having the colostomy care planned could lead to staff not knowing that he had a colostomy or if he cared for and maintained it himself. Review of facility's policy Care Plans, Comprehensive Person-Centered revised March 2022 revealed: A comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision. The facility failed to ensure CNA-E and CNA-F locked the Resident wheelchair during the Hoyer transfer of Resident #28. This failure could place residents at risk of injuries. Findings included: Review of Resident # 28's face sheet dated 07/16/2024 revealed an [AGE] year-old female admitted on [DATE]. Review of Resident #28's diagnosis revealed: hypertension (high blood pressure), disorder of muscle, degenerative disease of the nervous system, muscle wasting, and atrophy. Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 12 (moderately impaired). Section GG-Functional Abilities and Goals, Mobility Devices-uses Wheelchair (manual or electric), Mobility- E. Chair/bed-to chair transfer: Dependent-Helper does ALL the effort. Resident does none of the effort to complete the activity. Review of Resident #28's Care Plan dated 06/27/2024 revealed, Problem-I am limited in ability to transfer self R/T (related to) muscle weakness. Goal-Resident will be transferred with use of Hoyer lift. Approach-Use Hoyer lift for transferring. During an observation on 06/12/2024 at 10:15 AM, CNA-E and CNA-F did not lock the wheelchair while Resident #28 was being transferred from her bed to her wheelchair during a Hoyer Lift transfer. During an interview on 07/15/2024 at 2:45 PM, CNA-F stated they were not taught to lock the brakes on the Hoyer or the wheelchair during a transfer, although she was trained. She stated she did not know what the policy revealed. During an interview on 07/15/2024 at 3:30 PM the DON stated the Hoyer lift was not supposed to be locked during a transfer of residents, but the wheelchair was. She stated the DON monitored. The DON stated the failure was that some policies were confusing on when to lock the Hoyer lift and/or wheelchair. She stated the negative impact in not locking the wheelchair during a transfer was the possibility of injury to residents. She stated her expectations were that they would review the facility transfer policy, re-educate, and make sure it did not happen again. Review of facility Hoyer lift manual, https://www.manualslib.com/manual/2889017/Invacare-Reliant-450.html?page=13#manual on 07/15/2024 revealed; Invacare does not recommend locking the rear casters of the patient lift when lifting an individual. Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Review of facility policy Lifting Machine, Using a Portable dated December 2013 revealed; Purpose-The purpose of this procedure is to help lift residents using a manual lifting device. Steps in the Procedure-To transfer a resident from a bed to a chair, you should: 1. Position the chair. If it is a wheelchair, be sure the wheels are locked.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 4 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. Findings included: During an observation on 07/14/2024 at 8:38 PM, there was an unlocked medication cart on the south hallway of facility with LVN-B out of line of site. The unlocked cart contained all prescription and Over the Counter medications that included, but not limited to eye meds, stool softeners, antipsychotics, insulins, blood pressure medications, and narcotics. During an interview on 07/14/2024 at 8:40 PM LVN-B stated, she was in charge of the medication cart. She stated she was passing medications to a resident and the cart should have been locked at all times when out of sight. She stated there were 19 resident medications stored in this medication cart. LVN-B stated the residents had the potential to obtain medications that were not theirs and possibly cause an allergic reaction. During an interview on 07/14/2024 at 8:49 PM the DON stated residents had the potential to obtain medications that were unsafe for them and cause possible harm such as an overdose or an allergic reaction if the medication cart were left unlocked. She stated the charge nurses, and the Nursing Department heads were to monitor the medication carts. She stated she was unsure where the failure was as this nurse was the charge nurse at this time. The DON stated her expectations were for the medication carts to be locked at all times when not in use or out of sight. Review of facility policy Security of Medication Cart dated April 2007 revealed: Policy Statement- The medication cart shall be secured during medication passes. Policy Interpretation and Implementation; 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. Then it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 of 14 (Resident #29) residents reviewed for resident records. The facility failed to ensure Resident #29 had orders for weekly skin assessments. This failure could place residents at risk of having errors with their care and treatment. The findings included: Record review of Resident #29's electronic face sheet, dated 07/16/2024, revealed an [AGE] year-old female who admitted [DATE] with diagnoses: unspecified dementia, repeated falls, depression, hypertension (high blood pressure) heart failure, type ii diabetes mellitus with diabetic nephropathy (kidney disease), and pain disorder with related psychological factors. Record review of Resident #29's admission MDS dated [DATE], Section C-Cognitive Pattern revealed resident #29 had a BIMS score of 8, meaning the resident had moderately cognitively impaired. Section M Skin Conditions revealed no pressure ulcers. Record review of Resident #29's MAR (May 2024 MAR, June 2024 MAR, and July 2024 MAR) revealed no evidence that skin assessments were completed until 07/03/2024. During an interview on 07/16/24 at 10:30 AM LVN A stated that skin assessments should have been done weekly, starting at admission. LVN A stated the admitting nurse would have been responsible to add the order for skin assessments. LVN A stated if there was an order then it would have populated on a specific day and shift weekly to be completed on the nurses MAR. During an interview on 07/15/2024 at 2:40 PM the DON stated her expectation was skin assessments were to be completed weekly, starting at the time of admission. The DON stated she did not think there was a negative effect to residents because staff were doing daily foot soaks and the resident was receiving showers, so staff were looking at her skin, it was just not documented. The DON stated there should have been an order for weekly skin assessments written at admission. The DON stated what led to failure was that the admission nurse did not follow the facility's admission Checklist and she thought she must have used the orders from the previous facility. Review of facility document titled, admission Checklist, not dated, revealed Add orders into Matrix Review of the facility policy titled; Pressure Ulcer Risk Assessment dated September 2013 revealed Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis . Once inspection of skin is completed proceed to the admission Assessment or Weekly Skin Integrity tool and completed documentation of findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 14 (Resident # 29, #30, and #37) residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans that incorporated Resident #30 and #37's to include the use psychotropic medications. The facility failed to develop care plan that incorporated Resident #29's identified pressure ulcers. These failures could place the residents at risk for decreased quality of life and not having their needs met. The findings included: Record review of Resident #29's electronic face sheet, dated 07/16/2024, revealed [AGE] year-old female who admitted [DATE] with diagnoses: Unspecified dementia, repeated falls, depression, hypertension (high blood pressure) heart failure, type II diabetes mellitus with diabetic nephropathy (kidney disease), and pain disorder with related psychological factors. Record review of Resident #29's admission MDS dated [DATE], Section C-Cognitive Pattern revealed resident #29 had a BIMS score of 8, meaning resident had moderately cognitively impaired. Section M Skin Conditions revealed no pressure ulcers. Record review of Resident #29's MAR dated 06/01/2024-06/30/2024 revealed documentation of: Soak foot in 3 quarts of water with 10 mL of Clorox/bleach daily x 2 weeks. MAR dated 07/01/2024-07/16/2024 revealed: Cleanse areas to bilateral heels, right lateral foot, right ankle with normal saline/wound cleanser pat dry, apply skin prep to bilateral heels, right lateral foot, and right ankle. Weekly skin (specify day and shift) (This was not initiated until 07/03/2024). Record review of Resident #29's Care plan dated 05/14/2024, revealed no evidence, goal, or interventions of pressure ulcers to right and left heel. Record review of Resident' #30's electronic face sheet dated, 07/16/2024, revealed [AGE] year-old male who was admitted [DATE] and readmitted [DATE] with diagnosis type II diabetes mellitus, dysphagia , retentions of urine, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood , symptomatic epilepsy, pain in left knee, depression, unspecified convulsions, and chronic kidney disease. Record review of Resident #30's Significant change MDS dated [DATE] revealed: Section C Cognitive Patterns revealed Resident #30 had a BIMS score of 13, meaning resident had intact cognitive status. Section N revealed no use of anti-depressants, or anti-anxiety medications. Record review of Resident #30's physician orders dated 07/01/2024, revealed orders for Bupropion ER (extended release) 150 mg by mouth every day, Escitalopram 10 mg by mouth every day, Mirtazapine 15 mg by mouth at bedtime, Depakote sprinkles 125 mg, 3 tabs by mouth two times a day, Phenytoin 100 mg by mouth four times a day, and Tramadol 50 mg by mouth every four hours as needed for pain. Record review of Resident #30's Care plan dated 06/12/2024, revealed no evidence, goal, or interventions for the following medications: Bupropion (anxiolytic-to treat anxiety), Escitalopram (anti-depressant), Mirtazapine (anti-depressant), Depakote sprinkles (anti-epileptic/seizure), phenytoin (anti-convulsant), and Tramadol (narcotic used for pain relief). Record review for Resident # 37's electronic face sheet dated 07/16/2024, revealed a [AGE] year-old male admitted on [DATE] with diagnoses: Hemiplegia (complete or severe paralysis on one side) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left non-dominant side, vascular dementia (brain damage caused by multiple strokes) mild, with psychotic disturbance, and psychotic disorder with delusions. Record review of Resident #37's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns revealed Resident #37 had a BIMS score 15 meaning the resident had intact cognitive status. Record review of Resident # 37's Physician orders dated 07/01/2024 revealed: Clopidogrel 75 mg by mouth once a day, Aricept (donepezil) 5 mg by mouth once a day. Record review of Resident #37's Care Plan dated 03/08/2024 revealed: there were no goals, interventions for the diagnosis of Hemiplegia, Hemiparesis, or the use of Aricept (medication for dementia) or clopidogrel (blood thinner) in the care plan. During an interview on 07/15/2024 at 2:30 PM the ADON stated, herself and the DON were responsible to update care plans. The ADON stated a new pressure ulcer should be updated in the care plan upon finding the pressure ulcer. During an interview on 07/15/2024 at 2:40 PM the DON stated her expectation was that care plans should include resident needs and address ways to support their needs. The DON stated, herself and the ADON were responsible for updating the care plans. The DON stated she did not feel there was a negative impact to residents for care plans not being accurate because staff usually go by the orders not the care plan. The DON stated what led to the failure of items not being addressed in the care plan was that she was new to the long-term care process, and she was still learning. During an interview on 07/16/24 at 12:21 PM, the DON stated not all care plans had been reviewed and updated. The DON stated medications should have been care planned. The DON stated there was no harm to residents, but the care plan does help staff to know interventions planned for resident. The DON stated that she and the ADON were responsible for auditing and ensuring accuracy of care plans. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated Revised December 2016: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment 7. The care planning process will: a. facilitates resident and/or representative involvement. b. Include an assessment of the resident's strengths and needs; 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well -being; g. Incorporate identified problem areas .

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for halls 1 of 3 halls. The facility staff (CNA C) failed to place dirty linens in a sealed bag before being transported from resident room. The facility staff failed (CNA D) to place dirty briefs after peri-care in a sealed back before being transported from resident room. These failures could place residents at risk for the spread of infection and skin complications. Findings included: During an observation on 07/14/2024 at 8:36 PM, CNA-D was carrying unbagged dirty briefs through the hallway to the dirty bins. During an interview on 07/14/2024 at 8:36 PM, CNA-D stated she was carrying dirty briefs unbagged from resident room to the dirty bin because she had not taken an extra trash bag to place them in. She stated all dirty linens and briefs should be bagged and sealed before transporting them outside of resident rooms. She stated in doing so, she could have caused cross contamination between residents and/or staff members. During an observation on 07/15/2024 at 10:00 AM, CNA-C was carrying unbagged dirty resident sheets through hallway to the dirty bins. During an interview on 07/15/24 at 11:13 AM, CNA-C stated she was carrying linens from a resident room to the dirty linen closet that was un-bagged. She stated she had training on infection control and how to properly transport them from resident rooms to the dirty laundry. CNA-C stated she sat them down on the floor outside of the laundry room door to obtain a bag to put them in and stated she knew that was not the correct way to transport linens. She stated the linens should have been bagged and sealed before leaving resident room. CNA-C stated, carrying the unbagged linens from a resident room this way could have caused cross contamination from resident to resident. During an interview on 07/15/2024 at 4:03 PM the DON stated, all staff were to bag dirty linens and briefs before leaving rooms. She stated anything from resident's rooms should not be un-bagged when coming out to their room. The DON stated all staff should have been monitoring, but the ADON monitors most of the time. She stated the negative impact would have been cross contamination which would lead to the spreading of infection and/or germs. The DON stated the failure occurred with the CNA's rushing and hurrying to get their duties finished, that led to forgetting what was needed to finish the task properly. She stated her expectations were to have staff reeducated with infection control and the proper way of transporting linens and dirty briefs when it came to leaving resident rooms. The DON stated if linens were clean or dirty, they were to be bagged in and bagged out. During an interview on 07/16/2024 at 2:48 PM the ADON stated it was unacceptable to carry dirty briefs down the hallway without being bagged. She stated in-services were provided to all staff in May 2024 on Infection Control. She stated the negative impact to residents to residents transferring bacteria, which would lead to residents getting sick. She stated residents were immunocompromised and they could get sick easier. The ADON stated the DON and herself monitored, and the failure occurred with staff not following through with in services and competencies. She stated her expectations were to follow the policies. Record review of facility policy titled Infection Prevention and Control Program dated 1/1/2024 revealed: Policy: this facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 3. Standard precautions; a. All staff shall assume that all residents are potentially infected or colonized with an Organism that could be transmitted during the course of providing resident care services 12. Linens: a. Laundry and direct staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linens shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linen unless it is properly bagged.

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 100 of 403 (June 8, 2023 to July14, 2024) days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 06/09/2023, 06/10/2023, 06/11/2023, 06/16/2023, 06/17/2023, 06/18/2023, 06/24/2023, 06/25/2023, 07/01/2023, 07/02/2023, 07/05/2023, 07/06/2023,07/07/2023, 07/08/2023,07/09/2023, 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/24/2023, 07/25/2023, 07/26/2023, 07/27/2023, 07/28/2023, 07/29/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/02/2023, 09/03/2023, 09/09/2023, 09/10/2023, 09/16/2023, 09/17/2023,09/24/2023, 09/30/2023, 10/01/2023, 10/07/2023, 10/08/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, 11/05/2023, 1/11/2023, 11/12/2023, 11/18/2023, 11/19/2023, 11/25/2023, 11/26/2023, 12/02/2023, 12/03/2023, 12/09/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/28/202, 12/29/2023, 12/30/2023, 12/31/2023, 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/204, 01/21/2024, 05/04/2024, 05/05/2024, 05/12/2024, and 06/23/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of the facility's RN coverage tracking from 06/08/2023 to 07/14/2024 revealed 06/09/2023, 06/10/2023, 06/11/2023, 06/16/2023, 06/17/2023, 06/18/2023, 06/24/2023, 06/25/2023, 07/01/2023, 07/02/2023, 07/05/2023, 07/06/2023,07/07/2023, 07/08/2023,07/09/2023, 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/24/2023, 07/25/2023, 07/26/2023, 07/27/2023, 07/28/2023, 07/29/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/02/2023, 09/03/2023, 09/09/2023, 09/10/2023, 09/16/2023, 09/17/2023,09/24/2023, 09/30/2023, 10/01/2023, 10/07/2023, 10/08/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, 11/05/2023, 1/11/2023, 11/12/2023, 11/18/2023, 11/19/2023, 11/25/2023, 11/26/2023, 12/02/2023, 12/03/2023, 12/09/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/28/202, 12/29/2023, 12/30/2023, 12/31/2023, 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/204, 01/21/2024, 05/04/2024, 05/05/2024, 05/12/2024, and 06/23/2024 there was no evidence of RN coverage. During an interview on 07/16/24 at 2:23 PM the DON stated she was responsible for scheduling RN coverage and her expectation was to have 8 hours RN coverage daily. The DON stated she was hired August 2023 and she monitored RN coverage by the schedule she made. The DON stated she did not feel there was a negative effect on residents not having 8-hour RN coverage. The DON stated RN coverage was to help oversee and support the LVN's. The DON stated she was available by phone and could have come to facility. The DON stated whet led to the failure were RN's not wanting to work full shifts. During an interview on 07/16/24 at 2:41 PM the ADMN stated his expectation was to have appropriate RN coverage as required. The ADMN stated he did not think there had been a negative affect to residents because staff had access to an RN and the DON. The ADMN stated the DON was responsible to create the schedule and he assisted in monitoring. The ADMN stated what led to the failure of not having 8-hour RN coverage was a shortage of RN 's in the area, and not being able to cover when staff called in and the DON was out for surgery. The ADMN stated between sister facilities staff always had the resource of contacting a RN. The ADMN did not think they had a policy for RN coverage, they followed the federal guidelines.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, appearance, and temperature. The facility failed to ensure that 38 of 38 residents who received meals from the kitchen received food that was palatable, attractive, and at a safe and appetizing temperature. This failure place residents at risk of poor food intake and/or dissatisfaction of meals served. The findings were: During an observation on 07/14/2024 at 12:40 PM, the kitchen staff were plating the lunch meal and placing lids on top of meals that do not fit and some were cracked. The plated meals placed on the rolling cart were to be delivered to the residents who chose to eat in their rooms. This state surveyor monitored the test tray from the kitchen to last meal served to residents and proceeded to take the test tray to the conference room for other state surveyors to sample. During an observation on 07/14/2024 at 12:44 PM, the sample meal tray temperatures of the food were taken by the Cook. The temperatures were: pork roast was 85 degrees and was cold and tough, stuffing was 90 degrees and cool to the touch, green beans were 80 degrees and cold to taste, the roll was soggy on the bottom, and the vanilla pudding had clumps of pudding mix and did not have a smooth texture. During an interview on 07/14/2024 at 12:44 PM the [NAME] stated that she had cooked the food and did not want to test it. During an interview on 07/14/2024 at 12:48 PM the DM stated she believed the food was at the correct temperature and declined trying anything on the test tray. The DM stated her expectation was that the food temperature would be at 100 degrees or above. The DM stated all residents eat meals from the kitchen. During an interview on 07/14/2024 at 11:26 AM, Resident #37 stated vegetables were too mushy to eat and most of it was boiled, canned vegetables with no taste. During an interview on 07/14/2023 at 03:10 PM, Resident #30 stated the food was not hot, or warm. Resident #30 stated he was on a mechanical soft diet and the food did not taste good. Resident #30 stated he would have liked his food to be hot and he would put ketchup or something on it so he could eat the food. During an interview on 07/16/2024 at 12:21 PM, the DON stated she expected food to be served at the correct temperatures. The DON stated the failure occurred due to not having plate warmers and lids for the plates did not fit correctly and caused food to cool down. The DON stated residents could lose weight if not eating meals because the food was not warm or hot. During an interview on 07/16/24 at 02:46 PM the ADM stated his expectation was food served to the residents be warm, palatable, and timely. The ADM stated the effect on residents were if the food was cold residents would not eat the food. The ADM stated the DM monitors food temperatures and timeliness of food being served. The ADM stated food not being served in a timely manner caused the food to be cold when served to residents. Review of facility's policy titled and dated: Food Preparation and Service-Policy Statement-Food service employees shall prepare and serve in a manner that complies with safe food handling practices. Revised July 2014 Food Preparation, Cooking and Holding Temperatures and Times .2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese .5. The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms. a. poultry and stuffed foods-165 degrees. b. Ground meat, ground fish and eggs held for service-at least 115 degrees. c. fish and other meats- 145 degrees for 15 seconds. d. Fresh, frozen, or canned fruits/vegetables-135 degrees .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 3 (Resident #2) residents reviewed for urinary catheter care. The facility failed to place Resident #2's urinary catheter in a privacy bag. This failure could place residents at risk of low self-esteem resulting in a diminished quality of life. Findings include: Record review of the MDS dated [DATE] revealed Resident #2 was a [AGE] year old female admitted [DATE], with a BIMS score of 12 indicating mild cognitive impairment. Medical Diagnoses include nausea with vomiting, muscle weakness, muscle wasting and atrophy, obesity, pressure ulcer of sacral region and cellulitis. Record review of Residents #2 Care Plan dated 10/16/23, Category Urinary Incontinence, stated 'store collection bag inside a protective dignity pouch'. Observation and interview on 12/7/23 at 9:51 a.m., revealed Resident #2 lying in bed watching tv, the urinary catheter bag was placed on the right side down by the foot of the bed, no privacy cover and urinary catheter bag can be seen from hallway. Resident #2 stated she did not know the catheter bag did not have a privacy cover and stated she would like for it to be covered. In an interview with the DON on 12/7/23 at 10:18 a.m., the DON stated she expected that all catheter collection bags on beds and wheelchairs be covered by privacy pouch. The DON stated the failure of not placing catheter collection bags in privacy pouches could compromise a residents' dignity. Observation on 12/7/23 at 11:00 a.m., Resident #2 catheter bag was placed in privacy pouch. A policy on catheter care was requested but was not provided by the time of exit.

**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 needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed to ensure Resident #6's nebulizer tubing was kept in bag while not in use. These failures could place residents at risk for respiratory infections. The findings include: Record review of Resident #6's MDS admission assessment dated [DATE], revealed Resident #6 was admitted to the facility on 10/27/23. Section C: Cognitive Patterns revealed a BIMS score of 14 (cognitive). Section I: Active diagnosis revealed Congestive heart failure. Section O did not include the use of nebulizer. Record review of Resident #6's prescription order start date 12/4/23, Resident #6 was to receive, ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1; inhalation 2x daily, once during the day and once during the night. Record review of Resident #6's Care Plan revealed reoccurring episodes of wheezing, Goals: improve by Respiratory by changing tubing weekly per facility policy. In an observation and interview on 12/7/23, at 9:30 a.m., Resident #6 was lying in bed watching tv, the nebulizer was sitting on the nightstand on the right-side of the bed, the nebulizer tube and cup was not in a plastic bag for storage when not in use. Resident #6 stated that the last treatment was last night on 12/6/23 at 9:30pm. In an interview with the DON on 12/7/23 at 10:18 a.m., the DON stated she expected the nebulizer cup and tubing be changed once per week, dated, and stored in baggie when not in use. The DON stated the failure to store nebulizer cup and tubing properly could result in infection. The DON provided facility policy and procedure. Record review of the policy titled Respiratory Therapy- Prevention of Infection, 2001 MED-PASS, Inc. (Revised November 2011) Indicated: Section: Infection Control Consideration Related to Medication Nebulizer/Continuous Aerosol: Step 7. Store the circuit in plastic bag between uses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 2 (Resident #16 and Resident #27) of 4 residents reviewed for discharge. The facility failed to notify Resident #16 or her representative of her transfer in writing. The facility failed to notify Resident #27 or his representative of his transfer in writing. These failures place residents and/or their resident representatives at risk of understanding the reasons and/or location of transfers. Findings included: Resident #16 Record review of Resident #16's Face sheet dated 06/07/23 revealed a [AGE] year-old female with an admission date of 02/27/23. She had a diagnosis list that included: cardiomyopathy (Primary), anxiety disorder, ankylosing spondylitis, generalized edema, adverse effect of stimulant laxative, rheumatoid arthritis, idiopathic progressive neuropathy, hypertension, hyperkalemia, CHF, heart disease, COPD, type 2 diabetes without complication, anorexia. Record review of Resident #16's Census dated 06/07/23 revealed a discharge with an expected return on 05/23/23 and 06/02/23. Record review of Resident #16's Progress Notes revealed: 05/23/2023 08:45 AM called Dr office at 0810 explained resident's current condition and MD stated to send her to (hospital) to be checked out. Called @ 0820 (emergency contact) and notified him of his mother's condition. Called dispatch at 0825 for transportation to hospital. EMT's arrived at facility at 0830. Printed ccd and gave EMT's a copy and a copy of resident's vital signs from this morning. Resident left facility at 0835 via stretcher. 06/02/2023 05:36 PM. Was called to resident's room by resident's daughter . Resident's V/S T: 97.7 P:79 R:24 B/P: 120/79 SPO2: 95% via NC. Resident is difficult to arouse, disoriented, and lethargic. Called Dr. and MD stated to send resident out to the emergency room. Dispatch called at 1735. Family with resident at this time and are aware of change in condition. Notified DON of resident being sent out. Resident #27 Record review of Resident #27's Face sheet dated 06/07/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included Acute respiratory failure with hypoxia (Primary), stage 2 pressure ulcer of sacral region, pneumonia, neuromuscular dysfunction of bladder, dementia, Record review of Resident #27's Census dated 06/07/23 revealed a discharge with an expected return on 05/05/23. During an interview on 06/07/23 at 2:30pm with ADM and DON, they said they did not provide Resident #16 or Resident #27 or their representatives written notice of their transfers. DON said both residents were transferred to the hospital and had to be admitted to the hospital for a period of time. ADM said he was not aware that the facility needed to provide them with a written notice of their transfers when they went to the hospital. Record review of facility policy labeled Transfer or Discharge; Emergency last revised September 2012 revealed: Prepare a transfer form to send with the resident.

**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 time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for two (Resident #21, Resident #33) of eight residents reviewed for care plans, in that: The facility failed to address the care and monitoring of Resident #21's left lower leg prosthetic and the risk for skin breakdown on the comprehensive care plan. The facility failed to address the care and monitoring of Resident #33's indwelling urinary catheter and colostomy These failures could place residents at risk for not having their needs met. Findings included: Review of Resident #21's face sheet revealed a [AGE] year-old female initially admitted [DATE] with most recent admission on [DATE]. Resident #21's diagnoses included peripheral vascular disease (problems with the circulation of blood in the arms and/or legs), heart failure, kidney failure, lower left leg amputation, and type 2 diabetes. Review of Resident #21's 1 - 5-day Scheduled Assessment MDS dated [DATE], Section C: Cognitive Patterns, C0500. BIMS Summary Score revealed a BIMS score of 15 on a 1- 15 scale indicating intact cognition. Observation and interview on 06/05/23 at 11:09 AM, Resident #21 was propelling self in wheelchair down the hall. Right lower leg prosthetic was in place. Resident #21 denied issues with the prosthetic. Record review of Resident #21's care plan edited 06/01/2023 revealed a problem of Resident is at risk for pressure ulcer due to activity and chairfast. Interventions included Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair, Consider PT consult for conditioning and W/C assessment, and Teach or do frequent small shifts of body weight. Record review of Resident #21's MDS 1-5 day Scheduled assessment dated [DATE] revealed in section GG0110 Prior Device Use, choice E. Orthotics/Prosthetics was checked. Record review of Resident #33 face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident was diagnosed with constipation but did not have a diagnosis that would relate to the need for a urinary catheter. Record review of Resident #33 admission MDS dated [DATE] revealed a BIMS of 11 meaning mild cognitive decline, resident had an indwelling urinary catheter and a colostomy. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing an indwelling urinary catheter or the use of a colostomy. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for indwelling urinary catheter care, monitoring, changing, or discontinuing. Further review also revealed no orders for colostomy care, monitoring the stoma site, changing the wafer and fecal collection bag or During an observation and interview with Resident #33 on 06/05/23 at 3:30 PM revealed an indwelling urinary catheter draining to gravity with 1000 mLs of amber colored urine. He also had a colostomy on his left lower quadrant of his abdomen. Resident said he had the catheter and colostomy before he came into the facility however, he could not remember why he had either. During an interview with the DON on 06/07/23 at 3:40 PM, she said resident's that have indwelling catheters should have a diagnosis relating to the catheter. She said they should have physician's orders for the catheter that would include changing the catheter PRN, what size catheter to use when changing it, recording output each shift, and monitoring for any issues. She said evidence-based practices no longer indicated that Foley catheters should be routinely changed on a monthly basis, but that they would be changed as needed when residents were having difficulties, bladder pain, obvious sediment in the bag, leaking of the catheters, or when a resident would pull it out accidentally. DON also said that if a resident had an indwelling catheter, then the catheter would be addressed on a resident's care plan. She said resident's that had colostomies should have had a diagnosis relating to the colostomy. She said they should have physician's orders for the colostomy that would include changing the wafer and feces collection bag PRN, recording output each shift, and monitoring for any issues. DON also said that if a resident had a colostomy, then it would be addressed on a resident's care plan. DON stated there was no reason as to why the prosthetic use and skin issues were not care planned. Review of the facility policy titled Care Plans - Comprehensive revised September 2010 revealed under Policy Interpretation and Implementation item 1. Our facility's Care Planning Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Item 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem area, b. Incorporate risk factors associated with identified problems, c. Build on the resident's strengths, d. Reflect the resident's expressed wishes regarding care and treatment goals, e. Reflect treatment goals, timetables and objectives in measurable outcomes, f. Identify the professional services that are responsible for each element of care, g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and i. Reflect currently recognized standards of practice for problem areas and conditions. Item 7. The resident's comprehensive care plan is developed withing seven (7) days of the completion of the resident's comprehensive assessment (MDS). Item 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 (Resident #33) of 3 residents reviewed for indwelling catheters. The facility failed to have a diagnosis, physician orders and care plan interventions for Resident # 33's indwelling urinary catheter. These findings place resident at risk of complications related to urinary catheterization. Findings included Record review of Resident # 33 Face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident did not have any diagnosis that would relate to the need for a urinary catheter. Record review of Resident #33 admission MDS 05/12/23 reveal a BIMS of 11 meaning mild cognitive decline and resident had an indwelling urinary catheter. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing indwelling urinary catheter. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for indwelling urinary catheter care, monitoring, changing or discontinuing. During an observation and interview on 06/05/23 at 3:30 PM with Resident #33, he had an indwelling urinary catheter draining to gravity with 1000CC's of amber colored urine. Resident said he had the catheter before he came into the facility however, he could not remember why he had the catheter. During an interview with the DON on 06/07/23 At 3:40 PM. She said resident's that had indwelling catheters should have a diagnosis relating to the catheter. She said they should have physician's orders for the catheter that would include changing the catheter PRN, what size catheter to use when changing it, recording output each shift, and monitoring for any issues. She said evidence-based practices no longer indicated that Foley catheters should be routinely changed on a monthly basis, but that they would be changed as needed when residents were having difficulties, bladder pain, obvious sediment in the bag, leaking of the catheters, or when a resident would pull it out accidentally. DON also said that if a resident had an indwelling catheter, then the catheter would be addressed on a resident's care plan. Record review of facility policy labeled Catheter Care, Urinary last revised October 2010 revealed: review the Resident observe the resident urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident daily output, per facility policy and procedure. Check the resident frequently to be sure he or she is not laying on the catheter and to keep the catheter and tubing free of kink. Unless specifically ordered, do not apply clamp to the catheter. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Routine hygiene is appropriate. Empty the drainage bag regularly using a separate, clean collection container for each resident. Empty the collection bag at least every eight hours. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when they close system is compromised. Care plan to assess for any special needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with a colostomy receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s goals and preferences for 1 (Resident #33) of 2 residents reviewed for colostomies. The facility failed to have a diagnosis, physician orders, and care plan for Resident # 33's colostomy. These findings place resident at risk of complications related to a colostomy. Findings included Record review of Resident # 33 Face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. He had a diagnosis list that included constipation. Record review of Resident #33 admission MDS 05/12/23 reveal a BIMS of 11 meaning mild cognitive decline and resident had a colostomy. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing his colostomy. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for colostomy care, monitoring the stoma site, changing the wafer and fecal collection bag or. During an interview with resident #33 on 06/05/23 at 3:30 PM revealed a colostomy on his left lower quadrant of his abdomen. He said he had the colostomy before he came into the facility for the past year, however he could not remember what happened that caused him to get it. During an interview with the DON on 06/07/23 At 3:40 PM. She said resident's that had colostomies should have had a diagnosis relating to the colostomy. She said they should have physician's orders for the colostomy that would include changing the wafer and feces collection bag PRN, recording output each shift, and monitoring for any issues. DON also said that if a resident had a colostomy, then it would be addressed on a resident's care plan. Record review of facility policy labeled colostomy/ileostomy care last revised October 2010 revealed: review the resident's care plan to assess for any special needs of the resident . documentation. the following information should be recorded in the resident's medical record. the date and time the colostomy/ileostomy care was provided. The name and title of the individual who provided the colostomy/ileostomy care. Any breaks in the resident's skin, signs of infection, or excoriation of the skin. How the resident tolerated the procedure. If the resident refused the procedure, the reason why and the intervention taken. The signature and title of the person recording the data.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to label items in refrigerators and freezers. The facility failed to discard items in a timely manner that were stored in refrigerators and freezers. The facility failed to seal items that were stored in the refrigerators and freezers. These failures placed all residents at risk of complications of foodborne illnesses. Findings included: During an observation and interview on 06/05/23 at 08:45AM of the kitchen and food storage areas with the DM Refrigerator 1 (Near Door) 1 package of tortillas with an opened date of 4/3/23. DM said they were supposed to be thrown out after 7 days. 1 package of mozzarella shredded cheese with an opened date of 5/24/23. DM said the cheese should have been thrown out after 7 days. 1 package of sliced cheese with an opened date of 5/20/23. DM said it should have been thrown out after 7 days. 1-1-gallon container of bar-b-que sauce that was 1/2 empty with an illegible date opened on the bottle. 1 container of pimento cheese that was 3/4 empty that had no opened date on the container. DM said she did not know when it was opened. Refrigerator 2 (Near Sink) 1 carton of Thickened Orange Juice with an opened date of 5/23/23. The carton instructions state to use by 7 days after opening. DM was unaware how long the juice lasted. 1-32oz jug of Almond Milk that was 1/2 full had an opened date of 3/25/23. DM said that it should have been thrown out within 7 days. 1 Hamburger meat roll, wrapped in foil with top open and exposed to elements, which was hanging over top of pan. The hamburger meat was next to cabbage on the bottom of the icebox. DM said there was the potential for the hamburger meat to drip onto the cabbage. Chest Freezer 1 large bag of yeast rolls that was unsealed. As DM picked up the bag, several of the frozen yeast rolls fell out of bag. DM had staff go out and get a new bag and placed the torn bag inside and used a twist tie to close the bag. Stand up Freezer #1 1 clear zipper sealed bag labeled turkey was dated 5/31/23 that was stored in the door, and it had noticeable ice crystals throughout the bag, touching the meat, edges of some of the fillets were noted to be white and yellow. 1 clear plastic bag labeled Pork Riblets that was unsealed had an illegible date on the bag. DM took the bag out then got a twist tie and wrapped the bag to seal it. 1 clear zipper sealed bag labeled Pork Chops that was dated 1/18/23 was stored in the door and the bag had noted ice crystals throughout the bag touching the meat. DM said that the items in the door of the stand-up freezer were not freezer burned with ice crystals in the bags. She said they had ice crystals in the bag because of times when the freezer door was open too long. DM said that it was not that the items would briefly thaw out but that the freezer door would be left open. During an interview on 06/05/23 at 09:49 AM- DM said she checked the refrigerators daily for items that needed to be thrown out and looked in the freezers weekly on Wednesdays before the food supply trucks came in. Facility policy labeled Food Receiving and Storage last revised December 2008 revealed: Food should be received and stored in a manner that complies with safe food handling practices . All foods must be stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) . Uncooked and raw animal products and fish will be stored separately in a drip=proof containers and below fruits, vegetables and other ready-to-eat foods.

Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed. The facility failed to have an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed from January 1, 2023, through June 4, 2023. These failures could place all residents at risk for their clinical needs not being met. Findings included: Review of Daily Staffing Data revealed the facility did not have the services of an RN on the following dates: January 1-2, 7 - 9, 14 - 15 and 28 - 29, 2023; February 4- 5, 11 - 12, 19 and 26, 2023; March 11 - 12, 18 - 19 and 25 - 26, 2023; April 1 - 2, 7 - 9, 15 - 16, 22 - 24 and 29 - 30; 2023. May 4, 6 - 8, 13 - 14, 20 - 21 and 28 - 31, 2023; June 1 - 3, 2023. During an interview on 06/06/23 at 12:31 PM, the DON stated the facility had been having a hard time finding registered nurses to cover weekend shifts. The facility was advertising and had a Now Hiring banner in front of the building. The DON stated she would cover weekend shifts when she was able. During an interview on 06/07/23 at 2:03 PM, the Admin agreed with the DON that finding RN's was difficult in a small town. The Admin was not able to recall how long the facility had only the DON for RN coverage. Review of facility policy labeled Departmental Supervision revised August 2006 revealed: The nursing services department shall be under the direct supervision of a RN or LVN at all times. 1. A Registered or Licensed Practical/Vocational Nurse (RN/LPN, LVN) is on duty twenty-four hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a Nurse Supervisor/Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff.

**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 assured accurate administering of all drugs to meet the needs of the residents for 2 (Resident #1 and Resident #2) of 3 residents reviewed for medication regimen. 1. LVN A did not administer Resident #1's blood pressure medications within one hour before or after the scheduled administration time per facility policy. LVN A forgot to administer the medication when the resident was not immediately available for the administration. LVN A was notified by the surveyor that the resident had not recieved meds which prompted the nurse to give the meds. 2. RN A did not administer Resident #2's insulin within the one hour after the scheduled administration time per facility policy. RN A forgot to administer the medication when the resident was not immediately available for the administration. The deficient practice placed residents at risk of receiving less than therapeutic benefits from medications. Findings included: Record review of Resident #1's Face Sheet, dated 12/21/2022, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses were Chronic systolic (congestive) heart failure and Unspecified abnormalities of gait (manner or walking) and mobility. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #1's Pharmacy Order, dated 11/02/2022, revealed he was prescribed Amlodipine, for hypertension (high blood pressure), 5mg tablet, once a day, to be taken at 8:00 a.m. Record review of Resident #1' Prescription Order, dated 9/30/2022, revealed he was prescribed Carvedilol, for congestive heart failure, 6.25mg, 2 tablets, twice daily, with his first dose to be taken at 8:00 a.m. During an interview on 12/21/2022 at 10:45 a.m., Resident #1 said his knees were hurting and he had not told the nurse. Resident #1 said the reason he had not told the nurse was because he had not seen the nurse that morning. Resident #1 stated he had not taken his morning medication and said he was supposed to take them at 8:00 a.m. Resident #1 said he had pain medication he could take if he told the nurse he was hurting and asked to take the pills. During an interview on 12/21/2022 at 10:52 a.m., LVN A stated he had worked at the facility for four years. He said Resident #1 was supposed to receive his morning medication at 8:00 a.m., as documented on the eMAR. LVN A stated the first time he went to give Resident A his medication that morning, LVN A punched the pills out into a med cup and signed off on the eMAR electronic record as prepped and taken by resident #1, even though LVN A had not witnessed Resident #1 take his pills that morning. LVN A said he went down to Resident #1's room and he was not there, and he assumed Resident #1 was outside smoking. LVN A stated on his way back to the med cart, he tripped and dropped Resident #1's pills on the floor and disposed of them in the sharp's container. LVN A stated he forgot to go back and give Resident #1 his medication scheduled for 8:00 a.m. even though the time was now approximately 11:00 a.m. LVN A stated he had marked the eMAR that Resident #1 took his medication prior to the first attempt that morning, which was an error. LVN A stated he had been trained on medication administration and knew the correct time frame of giving medication was one hour before and one hour after the scheduled time. LVN A stated he had been trained on the eMAR electronic platform in October 2022 by the facility's DON and Regional Corporate staff. LVN A stated he knew he was not supposed to document on the eMAR the resident had taken his medication until he observed the resident to do so because it could cause major medication errors similar to the one he made with Resident #1. LVN A said med error could cause significant health issues. Observed Resident #1's eMAR for 12/21/2022 at 11:05 a.m. and noted the electronic record had been marked and documented that Resident #1 had taken his 8:00 a.m. medication but LVN A said he had not and prepared them and administrated them to Resident #1 at that time. Record review of Resident #2's Face Sheet, dated 12/21/2022, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses were Chronic diastolic (congestive) heart failure, Acquired absence of left leg below knee, and Type II diabetes mellitus with diabetic neuropathy (damage to the nerves). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #2's Pharmacy Order, dated 11/22/2022, revealed Resident #2 was prescribed Insulin Lispro, for diabetes, 100 unit/mL, subcutaneous (beneath the layer of skin), 3 times daily with the first dose at 9:00 a.m. During an interview on 12/21/2022 at 11:23 a.m., Resident #2 stated she was frustrated with RN A because she gave her medication to her late on Monday, 12/19/2022. Resident #2 said she was supposed to have received an insulin injection at 10 a.m. and she knew that she did not receive the medication until after lunch. Resident #2 said her blood sugar was not high due to receiving her insulin late, but she was worried it could be since it was time to receive her next scheduled shot. Resident #2 said she used her call button and called RN A several times to remind her, and RN A finally came and gave her the shot after 1:00 p.m. Resident #2 stated she thought the time was closer to 2:00 p.m. During an interview on 12/22/2022 at 10:15 a.m., RN A said she had been at the facility for approximately 1 ½ years. RN A stated she had been late on a medication with a resident earlier in the week and the resident was a diabetic and the medication had been an insulin shot. RN A identified the person as Resident #2 and stated Resident #2 should have received her diabetic shot at 9:00 a.m. before breakfast on 12/19/2022. RN A said the Insulin shot was scheduled for 9:00 a.m., but she forgot. RN A stated every time she went to give the shot to Resident #2, Resident #2 was involved in an activity. RN A did not state if she verbally inform Resident #2 that her insulin shot was due, but she said Resident #2 did not refuse as RNA stated she was in a hurry and did not have time to wait until Resident #2 was finished with the activity she was involved in. RN A said she could not remember what time she gave Resident #2 the injection, but she was sure the shot was given by 12:00 p.m. RN A said again said she had overlooked giving Resident #2 her insulin shot but she had several residents to give medication to and could not always go back to the med cart and use the computer to look at all residents who had not received medication. RN A said she knew Resident #1 not receiving her Insulin shot within the scheduled time frame could cause her blood sugar to become high and out of therapeutic range. Observation of the electronic eMAR for 12/19/2022 showed Insulin Lispro Solution, 100 unit/mL, scheduled: 9:00am, 12:00pm, and 5:00pm was completed as given on 12/19/2022 with no time stamp. During an interview on 12/21/2022 at 1:45 p.m., the DON stated she had been at the facility for approximately 1 ½ years. The DON said she was not aware LVN A had not administered the morning medication to Resident #1 until it was brought to her attention around 11:00 a.m. by the Surveyor. The DON stated her expectations were for the nurses or med techs to administer medication to the residents at the scheduled time within an hour before or after the time on the eMAR. The DON said if the medication was not taken within that time frame, the nurse was to document on the eMAR that the medication was missed and document the reason why. The DON said Resident #1, who received his medication late because he was outside smoking, was unacceptable and did not meet her expectation. The DON said she was not aware that Resident #2 did not receive her insulin injection until RN A came to her and told her what happened after she talked to the surveyor, which was unacceptable. The DON said this was unacceptable because the resident could have negative effects with her blood sugar which would be medically dangerous. The DON said she and the Executive Director were available if staff needed assistance and the facility provided education and held the staff accountable. During an interview on 12/12/2022 at 12:50 p.m., the Executive Director said she was not aware nursing staff were administering medication outside the required time frame and this did not meet her expectation and was not how the staff were trained. The Executive Director said policy stated the timeframe was within an hour of the scheduled med time, meaning an hour before or after. She also stated the nurse should document if the medication was late and notify the DON or herself. The Executive Director said she was not aware that RN A had given Resident #2 her insulin injection late until after it was discovered during the review on this date and that was unacceptable. Record review of the Performance Improvement Plan for (electronic) eMARs & POC Uplift, dated 10/20/2022, revealed on-site eMAR/POC training with staff by DON/Nurse Managers, MDS - would train staff on the units with Regional support. Record review of the Administering Medication Policy, dated 12/2012, revealed medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time. Record review revealed the individual administering the medication must initial on the resident's MAR (eMAR) on the appropriate space after giving each medication and before administering the next ones. For residents not in their rooms or unavailable, the MAR (eMAR) must be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication.