**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #28) reviewed for care plans. The facility failed to invite and include the input of Resident #28 and/or residents' representative as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the residents' representative in Care Plan Conference meetings. The findings included: Record review of Resident #28's face sheet, dated 10/18/2024, reflected a [AGE] year-old male resident initially admitted on [DATE] with diagnosis including diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that affects one side of the body after a stroke causing paralysis), and dysphagia (difficulty swallowing). No diagnosis of dementia was present on Resident #28's face sheet. Record review of Resident #28's MDS Assessment, dated 10/8/2024, reflected Resident #28 had a BIMS score of 8, suggesting moderate impairment. No diagnosis of dementia was present on Resident #28's MDS assessment. During an interview on 10/14/2024 at 12:39 PM, Resident #28 and FM stated that they had not been invited to any care plan conference meeting prior to the one they were invited to which was being held that day, 10/14/2024. Resident #28's wife stated she was confident she had not been invited to any care plan conference meetings around the time Resident #28 arrived at the facility because she visits almost daily and would not have missed any care plan conference meeting or any meeting that related to Resident #28. During an interview on 10/18/2024 at 4:42 PM, the ADON, DON, and ADM, the ADON stated that she had a folder with care plan conference invitations in them. No invitation for Resident #28 and/or Resident #28's family member was found in the folder. The ADON stated that she was confident the facility invited Resident #28 and/or Resident #28's family member to their care plan conference meeting, but that Resident #28 and Resident #28's FM likely had dementia. The ADM stated that her expectation is for residents and their family members be involved in their care plan conference meetings. Record review of Resident #28's Electronic and Paper Health Record did not reflect any care plan conference invitations for any care plan conferences prior to 10/14/2024. Record review of facility policy, dated copyrighted 2005, titled, Care Plan/Comprehensive Interdisciplinary, reflected, The interdisciplinary team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The interdisciplinary team shall include: Resident (if possible), Residents family or POA, Social Worker, Dietary supervisor, Activities staff member, Director of Nurses, Any other staff member pertinent to residents care at the time.

**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, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #18) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #18's diagnoses of mental illness including depression. This failure could place residents at risk for not having their needs and preferences met. The findings included: Record review of Resident #18's face sheet, dated 10/18/2024, reflected a [AGE] year-old resident, initially admitted on [DATE], with diagnoses including pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe), depression, and dysphagia (difficulty swallowing). Record review of Resident #18's MDS Assessment, dated 9/22/2024, reflected Resident #18's takes antidepressants. Resident #18's MDS Assessment also reflected a BIMS of 14, indicating cognitively intact. Record review of Resident #18's Care Plan, undated, reflected a 5-page document without any interventions or mention of Resident #18's diagnosis of depression or antidepressant therapy. Interview on 10/18/2024 at 5:20 PM, the ADON stated she is responsible for care plans and ensuring they are done correctly and address all areas of care. The ADON stated she was not certain why Resident #18 did not have her diagnosis of depression on her care plan . The ADON stated she looks at assessments to complete care plans, and any input from other staff. Interview on 10/18/2024 at 5:25 PM, the ADM stated her expectation was for care plans to be done correctly. Record review of facility policy, dated copyrighted 2005, titled, Care Plan/Comprehensive Interdisciplinary, reflected, The care plan must include measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #28) reviewed for personal hygiene. The facility failed to provide Resident #28, 18 of 30 scheduled showers between 7/2/2024 and 10/15/2024. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #28's face sheet, dated 10/18/2024, reflected a [AGE] year-old male resident initially admitted on [DATE] with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that affects one side of the body after a stroke causing paralysis), and dysphagia (difficulty swallowing). Record review of Resident #28's MDS Assessment, dated 10/8/2024, reflected Resident #28 had a BIMS score of 8, suggesting moderate impairment. No diagnosis of dementia was present on Resident #28's MDS assessment . Resident #28's MDS assessment indicated that Resident #28 needed Partial/moderate assistance for bathing. Record review of Resident #28's Care Plan, undated, reflected interventions stating the resident had an ADL self-care performance deficit related to diagnosis of hemiplegia and hemiparesis. Interview on 10/14/2024 at 12:39 PM, Resident #28 and FM stated that Resident #28 only got showered once a week and would prefer to be showered at least twice a week, ideally on Tuesday and Saturday. Resident #28 stated he was not aware he should have been getting showered more than once weekly and was thankful to hear he could be showered more than once weekly. Record review of Resident #28's shower log reflected that the resident's shower days were Tuesday, Thursday, and Saturday. Further review revealed Resident #28 did not receive 18 of 30 instances of scheduled showers, with 1 instance of refusing a shower. Interview on 10/18/2024 at 5:22 PM, with the ADON, DON, and ADM, the ADON stated that Resident #28 and Resident #28's FM likely did not remember his showers correctly, as they likely had dementia. The ADON requested to interview Resident #28 in front of the surveyor and stated that she was confident Resident #28 would not say he only received showers once a week if the ADON asked Resident #28 in front of the surveyor. The ADM stated that her expectation was for residents to receive showers on their scheduled shower dates . Record review of facility policy, undated, titled, Bath, Shower reflected Residents are showered a minimum of three times weekly on one of two shower schedules either a Monday, Wednesday, & Friday or a Tuesday, Thursday, Saturday schedule which is determined by that patients charge nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents who had not used psychotropic drugs were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #13) reviewed for unnecessary medications. The facility failed to ensure Resident #13 was taking a psychotropic medication (Mirtazapine (an antidepressant)), to treat a specific diagnosed condition. This deficient practice could place residents at risk for receiving medications that were not necessary for their care. The findings include: Record review of the admission Record reflected Resident #13 was a [AGE] year-old resident who was initially admitted to the facility on [DATE]. Resident #13 had diagnoses which included essential hypertension (abnormally high blood pressure), and a pressure ulcer of the sacral region, stage 4. A diagnosis of depression was not documented. Record review of the comprehensive MDS assessment, dated 9/23/2024, reflected Resident #13's Section I - Active Diagnosis section of her MDS did not reflect a diagnosis of Depression. Resident #13' s BIMS score reflected a BIMS of 13, which indicated moderate cognitive impairment. Record review of Resident #13' s Order Summary Report, dated 10/18/2024, reflected an order for Mirtazapine Oral Tablet 15 MG with the instruction, Give 15 mg by mouth one time a day for depression. Record review of Resident #13' s MAR for October 2024, dated 10/18/2024, reflected Resident #13 was receiving Mirtazapine Oral Tablet 15 MG for depression. Interview on 10/18/2024 at 5:32 PM, the ADON stated she was not sure why Resident #13 did not have a diagnosis of depression . The ADON stated she was not certain who was responsible for ensuring residents have the correct diagnosis for psych medications. Record review of the facility's policy titled, Medications, Drug Regimen Reviews undated, reflected, Unnecessary Drugs: Drugs that are given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a diagnosis or reason for the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective se rvices where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 8 residents (Residents #5, #17, and #140) reviewed for reporting allegations of abuse, neglect, and exploitation. 1. The administrator failed to report an allegation of neglect, with serious injury, when Resident #140 was assisted with a mechanical lift transfer by 1 staff member, CNA A. Resident #140 fell during the transfer, suffered a broken right leg, and was hospitalized with a need for surgical repair. Prior to the fall Resident #140 was assessed with a need for more than 1 staff for assistance with transfers. 2. The administrator and the Social Worker failed to report an allegation of abuse on behalf of Resident #17. Resident #17 reported to CNA M, when she (Resident #17) was out on pass with a family member, she was nude and scared by a drunken, bloodied, family member and had to crawl to safety. 3. The administrator and the Social Worker failed to report an allegation of neglect on behalf of Resident #5 when CNA M alleged Resident #17 removed Resident #5's oxygen nasal cannula and oxygen concentrator because Resident #17 stated it was too loud and she (Resident #17) could not fall asleep. This deficient practice could place residents at risk for harm by not reporting allegations of abuse, neglect, and exploitation to the state agency. The findings included: 1. A record review of Resident #140's admission and discharge record dated [DATE] revealed an admission date of [DATE] and a discharge date of [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a condition of the mind or psyche that results in difficulties determining what is real and what is not real), mood disturbance and anxiety. A record review of Resident #140's quarterly MDS assessment dated [DATE] revealed Resident #140 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 01 out of a possible of 15 which indicated severe cognition impairment. Further review revealed Resident #140 was assessed as Dependent - helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the Resident to complete the activity for all of Resident #140's needs for transfers, sit to stand, chair / bed to chair transfer, and toilet transfers. A record review of Resident #140's care plan dated [DATE] revealed, (Resident #140) is dependent on staff for meeting . physical . needs . related to dementia . the Resident needs assistance / escort to activity functions A record review of the facility's fall incident report dated [DATE] revealed Resident #140 suffered a fall during a 1-person mechanical lift transfer . During an interview on [DATE] at 03:00 PM, the ADON stated Resident #140 was discharged to the hospital on [DATE] for evaluation and treatment for pain to her right leg and was diagnosed with a broken right leg which was surgically repaired. The ADON stated Resident #140's family did not return Resident #140 to the facility and moved Resident #140 to their home where they continued to care for her. The ADON stated on [DATE] CNA A alerted LVN B that she needed assistance with Resident #140 because CNA A lost control of Resident #140 during a transfer from the bed to a wheelchair. During an interview on [DATE] at 02:17 p.m., Resident #140's representative stated she received a report from LVN B on the evening of [DATE]. Resident #140's representative stated LVN B reported that CNA A alerted LVN B for assistance with Resident #140 and, when LVN B entered the room, she observed Resident #140 sitting on the floor on her bottom with her legs to the right and the mechanical lift nearby. LVN B assessed Resident #140 to be without pain and with one small skin tear to her arm. Resident #140's representative stated LVN B reported Resident #140 was placed in bed, her physician was called, and an order for an x-ray was obtained. Record review of Resident #140's nursing progress notes, revealed the DON documented on [DATE] at 09:00 AM, Resident #140 was in pain when CNAs attempted incontinent care. The DON communicated with the physician and transferred Resident #140 to the hospital for evaluation. A record review of Resident #140's admission Hospital records dated [DATE], revealed that Resident #140 was diagnosed with a right femur (leg) fracture. During an interview on [DATE] at 02:25 p.m., the ADON stated she learned CNA A had transferred Resident #140 from her bed to a wheelchair with a mechanical lift, a sit to stand lift, by herself. The ADON stated she learned this from the Administrator. The ADON stated the Administrator possessed written statements and audio recordings from CNA A and LVN B that confirmed CNA A transferred Resident #140 alone. ADON stated Resident #140 was assessed on the MDS as needing more than 2 persons assistance with all transfers. ADON stated her expectation, and the facility policy was residents who were assessed as needing 2 persons assistance with transfers would receive 2 persons assistance with transfers. ADON stated LVN B and CNA A were no longer employed by the facility, specifically CNA A was a temporary agency employee and was no longer invited back, and LVN B was terminated for other infractions. ADON stated Resident #140 had a history of not following commands, not cooperating with transfers, biting, and scratching staff when staff attempted assist Resident #140 with a transfer. ADON stated she and the Administrator reviewed the details of the fall with injury and concluded the event was not a reportable event since the injury, a broken leg, was not from an unknown source. During an interview on [DATE] at 02:50 PM, the Administrator and the ADON, ADON stated CNA A transferred Resident #140 by herself after LVN B warned her not to, due to Resident #140's lack of following commands and combativeness. Administrator and ADON stated CNA A and LVN B have been dismissed due to their poor performance and have not worked at the facility since [DATE] after the incident. Administrator stated she had audio recordings of her interviews with CNA A and LVN B and learned LVN B had warned CNA A not to transfer Resident #140 alone, but CNA A had transferred Resident #140 by herself with a sit to stand mechanical lift. Administrator stated she understood Resident #140 was assessed as needing more than 1 person to assist with all transfers due to residents' inability to follow commands and history of combativeness. Administrator stated she and the ADON reviewed the details of the incident and believed the incident with a broken leg would not be a reportable incident to the state agency because the injury was witnessed. Administrator stated she had not considered the 1-person mechanical lift was neglect. 2. A record review of the Resident #17's quarterly MDS assessment dated [DATE] revealed an admission date of [DATE] with diagnoses which included cerebral palsy (damage to brain areas that control muscle movement, or when those areas don't develop as they should), anxiety disorder, and psychotic disorder (a condition of the mind or psyche that results in difficulties determining what is real and what is not real). Further review revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13, out of a possible 15, which indicated intact cognition. A record review of Resident #17's nursing progress notes revealed Resident #17 went out on pass with her family member on [DATE] and returned on [DATE]: Effective Date: [DATE] 09:26:00 Department: Nursing Position: Registered Nurse Created By: RN (C) Created Date: [DATE] 10:31:17; Note Text: LEFT FOR 2 DAY PASS AT HOME WITH (family). LEFT VIA PRIVATE AUTO WITH WHEELCHAIR. MEDICATION FOR 2 DAYS SENT WITH PATIENT. INSTRUCTIONS FOR ADMINISTRATION GIVEN TO PATIENT AND (family). LEFT IN STABLE CONDITION. Activity Participation Note, Effective Date: [DATE] 15:28:00 Department: Activities Position: Activities Director Created By: (Activity Director) Created Date: [DATE] 15:28:21 Note Text: OOP (out on pass) for the day. Administration Note Effective Date: [DATE] 15:05:00 Department: Nursing, Position: Registered Nurse Created By: (RN G) Created Date: [DATE] 15:05:52, Note Text: Patient may have 6 ounces of wine QD. in the afternoon for Per patient's request, I just don't want the wine today. A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form for Resident #17 signed by the Social Worker, dated [DATE]. Further review revealed a written statement, dated [DATE], authored by CNA M which revealed Resident #17 while out on pass with family felt vulnerable while nude and threatened by a bloodied, drunken family member, I (CNA M) who works weekends was walking by Resident #17 and she stopped me to ask me how my New Year's was and I told her I was good. She then laughed and shook her head and told me she needed to talk to me later I said OK. I then after breakfast went in to get her bed made-up for the day and she told me her New Year's wasn't good. I ask why not and I'm sorry to hear that she then said her (family member) was drunk with a bloody nose and she was on the bed naked, and she was so scared she threw herself off the bed and pulled herself across the room to the restroom to get dressed and she just was so scared and wanted to (call for) help but couldn't call for any help. Further review revealed the social worker documented on the written statement, Resident is being seen by (psychiatric consultant) who has addressed this issue with the Resident. Social Worker spoke with resident about this on [DATE]. Resident stated she does not plan to go home out on pass with family member in the future. Signed Social Worker. During an interview on [DATE] at 08:50 a.m., Resident #17 did not want to participate in an interview regarding her New Year's Eve pass. During an interview on [DATE] at 3:30 PM, CNA M stated she recalled writing the statement on behalf of Resident #17's bad new year's pass and recalled the Social Worker was aware of the incident. CNA M stated the Social Worker (SW) had asked her to write the statement. During a joint interview on [DATE] at 03:05 PM, with the Administrator (ADM), the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the second page of the grievance which was the written statement of by CNA M. The ADM stated her expectation was for the SW to have reported the allegation of abuse to her. The ADM stated the allegation of abuse could have been reported and investigated. The ADON stated Resident #17 had a diagnosis of psychotic disorder and had voluntarily gone out on pass with family since February 2024. 3. A record review of Resident #5's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included heart failure, presence of cardiac pacemaker (a small implanted electrical device to periodically shock the heart to keep a regular heartbeat), and atrial fibrillation (an irregular heart beat out of sequence contributing to the formation of harmful blood clots.) A record review of Resident #5's annual MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care, assessed with a debility with breathing and circulation, and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. Further review revealed Resident #5 was assessed with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring); shortness of breath or trouble breathing when sitting at rest; and shortness of breath or trouble breathing when lying flat. Resident #5 was assessed as having a life expectancy of less than 6 months. A record review of Resident #5's care plan dated [DATE] revealed Resident #5 was received oxygen therapy and had interventions which included, . for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form dated [DATE], for Resident #17 which involved Resident #5, and was signed by the Social Worker. Further review revealed CNA M documented (Resident #17) has turned off (Resident #5's) O2 (oxygen) concentrator during the night shift because it is to (too) loud and she has an go up and took off her nasal cannula and put it in her drawer beside her bed when (Resident #5) does not get up out of bed as she does have a bed alarm. Further review revealed the SW documented, Findings: 3 concerns on this issue - SW spoke with Resident on [DATE] when concerns were submitted. Resident admitted to removing O2 cannula because Resident wasn't using it and turning the O2 concentrator off because it was too noisy and she couldn't sleep. Resolution: SW advised Resident (#17) that she is endangering her roommate (Resident #5). Resident (#17) became tearful and stated she would no longer turn the O2 concentrator off. Resident (#17) to be moved to another room ASAP. Resident (#17) advised she would be moving and agreed to do so. (signed by the SW). During an interview on [DATE] at 09:10 AM, Resident #5 could not recall any incidents regarding her use of oxygen. During an interview on [DATE] at 08:50 AM, Resident #17 did not want to participate in an interview regarding her previous roommate. During an interview on [DATE] at 08:50 AM, Resident #5 could not participate in an interview due to confusion. An attempt to interview Resident #5's representative was unsuccessful. During a joint interview on [DATE] at 03:05 PM, with the Administrator, the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the allegation of neglect and or abuse on behalf of Resident #5. The ADM stated the SW had not brought the allegation to her attention. The ADM stated the allegations of abuse and or neglect could have been reported to the state. A record review of the facility's undated Residents Abuse, Neglect or Mistreatment policy revealed, Policy: Each Resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse or involuntary seclusion. All facility staff shall be in-serviced upon employment and annually regarding residents right and freedom form abuse, neglect, mistreatment, and misappropriation of property. suspected or substantiated cases of Resident abuse, neglect, misappropriation of property or mistreatment shall thoroughly be investigated and documented by the administrator and reported to the appropriate state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action were taken, for 3 of 8 residents (rResidents #5, #17, and #140) reviewed for allegations of abuse, neglect, and exploitation. 1. The administrator failed to investigate and report an allegation of neglect, with serious injury, when Resident #140 was assisted with a mechanical lift transfer by 1 staff member, CNA A. Resident #140 fell during the transfer, suffered a broken right leg, and was hospitalized with a need for surgical repair. Prior to the fall Resident #140 was assessed with a need for more than 1 staff for assistance with transfers. 2. The administrator and the Social Worker failed to investigate and report an allegation of abuse on behalf of Resident #17. Resident #17 reported to CNA M, when she (Resident #17) was out on pass with a family member, she was nude and scared by a drunken, bloodied, family member and had to crawl to safety. 3. The administrator and the Social Worker failed to investigate and report an allegation of neglect on behalf of Resident #5 when CNA M alleged Resident #17 removed Resident #5's oxygen nasal cannula and oxygen concentrator because Resident #17 stated it was too loud and she (Resident #17) could not fall asleep. This deficient practice could place residents at risk for harm by not investigating and reporting allegations of abuse, neglect, and exploitation to the state agency. The findings included: 1. A record review of Resident #140's admission and discharge record dated [DATE] revealed an admission date of [DATE] and a discharge date of [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a condition of the mind or psyche that results in difficulties determining what is real and what is not real), mood disturbance and anxiety. A record review of Resident #140's MDS assessment dated [DATE] revealed Resident #140 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 01 out of a possible of 15 which indicated severe cognition impairment. Further review revealed Resident #140 was assessed as Dependent - helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the Resident to complete the activity for all of Resident #140's needs for transfers, sit to stand, chair / bed to chair transfer, and toilet transfers. A record review of Resident #140's care plan dated [DATE] revealed, (Resident #140) is dependent on staff for meeting . physical . needs . related to dementia . the Resident needs assistance / escort to activity functions A record review of the facility's fall incident report dated [DATE] revealed Resident #140 suffered a fall during a 1-person mechanical lift transfer. During an interview on [DATE] at 03:00 PM, the ADON stated Resident #140 was discharged to the hospital on [DATE] for evaluation and treatment for pain to her right leg and was diagnosed with a broken right leg which was surgically repaired. ADON stated Resident #140's family did not return Resident #140 to the facility and moved Resident #140 to their home where they continued to care for her. ADON stated on [DATE] CNA A alerted LVN B that she needed assistance with Resident #140 because CNA A lost control of Resident #140 during a transfer from the bed to a wheelchair. During an interview on [DATE] at 02:17 pm, Resident #140's representative stated she received a report from LVN B on the evening of [DATE]. Resident #140's representative stated LVN B reported that CNA A alerted LVN B for assistance with Resident #140 and, when LVN B entered the room, she observed Resident #140 sitting on the floor on her bottom with her legs to the right and the mechanical lift nearby. LVN B assessed Resident #140 to be without pain and with one small skin tear to her arm. Resident #140's representative stated LVN B reported Resident #140 was placed in bed, her physician was called, and an order for an x-ray was obtained. Record review of Resident #140's nursing progress notes revealed the DON documented on [DATE] at 09:00 AM Resident #140 was in pain when CNAs attempted incontinent care. The DON communicated with the physician and transferred Resident #140 to the hospital for evaluation. A record review of Resident #140's admission Hospital records dated [DATE], revealed that Resident #140 was diagnosed with a right femur (leg) fracture and was surgically repaired. During an interview on [DATE] at 02:25 pm ADON stated she learned CNA A had transferred Resident #140 from her bed to a wheelchair with a mechanical lift, a sit to stand lift, by herself. ADON stated she learned this from the Administrator. ADON stated the Administrator possessed written statements and audio recordings from CNA A and LVN B that confirmed CNA A transferred Resident #140 alone. ADON stated Resident #140 was assessed on the MDS as needing more than 2 persons assistance with all transfers. ADON stated her expectation, and the facility policy was residents who were assessed as needing 2 persons assistance with transfers would receive 2 persons assistance with transfers. ADON stated LVN B and CNA A were no longer employed by the facility, specifically CNA A was a temporary agency employee and was no longer invited back, and LVN B was terminated for other infractions. ADON stated Resident #140 had a history of not following commands, not cooperating with transfers, biting, and scratching staff when staff attempted assist Resident #140 with a transfer. The ADON stated she and the Administrator reviewed the details of the fall with injury and concluded the event was not a reportable event since the injury, a broken leg, was not from an unknown source. During a joint interview on [DATE] at 02:50 PM with the Administrator and the ADON, ADON and ADM stated CNA A transferred Resident #140 by herself after LVN B warned her not to due to Resident #140's lack of following commands and combativeness. Administrator and the ADON stated CNA A and LVN B have been dismissed due to their poor performance and have not worked at the facility since [DATE] after the incident. Administrator stated she had audio recordings of her interviews with CNA A and LVN B and learned LVN B had warned CNA A not to transfer Resident #140 alone but CNA A transferred Resident #140 by herself with a sit to stand mechanical lift. Administrator stated she understood Resident #140 was assessed as needing more than 1 person to assist with all transfers due to residents' inability to follow commands and history of combativeness. Administrator stated she and her ADON reviewed the details of the incident and believed the incident with a broken leg would not be a reportable incident to the state agency because the injury was witnessed. Administrator stated she had not considered the 1-person mechanical lift was neglect and thus there was no investigation and report to the state agency. 2. A record review of the Resident #17's quarterly MDS assessment dated [DATE] revealed an admission date of [DATE] with diagnoses which included cerebral palsy (damage to brain areas that control muscle movement, or when those areas don't develop as they should), anxiety disorder, and psychotic disorder (a condition of the mind or psyche that results in difficulties determining what is real and what is not real). Further review revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. A record review of Resident #17's nursing progress notes revealed Resident #17 went out on pass with her family member on [DATE] and returned on [DATE]: Effective Date: [DATE] 09:26:00 Department: Nursing Position: Registered Nurse Created By: RN (C) Created Date: [DATE] 10:31:17; Note Text: LEFT FOR 2 DAY PASS AT HOME WITH (family). LEFT VIA PRIVATE AUTO WITH WHEELCHAIR. MEDICATION FOR 2 DAYS SENT WITH PATIENT. INSTRUCTIONS FOR ADMINISTRATION GIVEN TO PATIENT AND (family). LEFT IN STABLE CONDITION. Activity Participation Note, Effective Date: [DATE] 15:28:00 Department: Activities Position: Activities Director Created By: (Activity Director) Created Date: [DATE] 15:28:21 Note Text: OOP (out on pass) for the day. Administration Note Effective Date: [DATE] 15:05:00 Department: Nursing, Position: Registered Nurse Created By: (RN G) Created Date: [DATE] 15:05:52, Note Text: Patient may have 6 ounces of wine QD. in the afternoon for Per patient's request, I just don't want the wine today. A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form for Resident #17 signed by the Social Worker, dated [DATE]. Further review revealed a written statement, dated [DATE], authored by CNA M which revealed Resident #17 while out on pass with family felt vulnerable while nude and threatened by a bloodied, drunken family member, I (CNA M) who works weekends was walking by Resident #17 and she stopped me to ask me how my New Year's was and I told her I was good. She then laughed and shook her head and told me she needed to talk to me later I said OK. I then after breakfast went in to get her bed made-up for the day and she told me her New Year's wasn't good. I ask why not and I'm sorry to hear that she then said her (family member) was drunk with a bloody nose and she was on the bed naked, and she was so scared she threw herself off the bed and pulled herself across the room to the restroom to get dressed and she just was so scared and wanted to (call for) help but couldn't call for any help. Further review revealed the social worker documented on the written statement, Resident is being seen by (psychiatric consultant) who has addressed this issue with the Resident. Social Worker spoke with resident about this on [DATE]. Resident states she does not plan to go home out on pass with family member in the future. Signed Social Worker. During an interview on [DATE] at 08:50 Resident #17 did not want to participate in an interview regarding her New Year's Eve pass. During an interview on [DATE] at 3:30 PM CNA M stated she recalled writing the statement on behalf of Resident #17's bad new year's pass and recalled the Social Worker was aware of the incident. CNA M stated the Social Worker had asked her to write the statement. During a joint interview on [DATE] at 03:05 PM with the Administrator, the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the second page of the grievance which was the written statement of by CNA M. ADM stated her expectation was for the SW to have reported the allegation of abuse to her. ADM stated the allegation of abuse could have been reported and investigated. ADON stated Resident #17 had a diagnosis of psychotic disorder and had voluntarily gone out on pass with family since February 2024. 3. A record review of Resident #5's admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included heart failure, presence of cardiac pacemaker (a small implanted electrical device to periodically shock the heart to keep a regular heartbeat), and atrial fibrillation (an irregular heart beat out of sequence contributing to the formation of harmful blood clots.) A record review of Resident #5's annual MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care, assessed with a debility with breathing and circulation, and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. Further review revealed Resident #5 was assessed with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring); shortness of breath or trouble breathing when sitting at rest; and shortness of breath or trouble breathing when lying flat. Resident #5 was assessed as having a life expectancy of less than 6 months. A record review of Resident #5's care plan dated [DATE] revealed Resident #5 was received oxygen therapy and had interventions which included, . for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form dated [DATE], for Resident #17 which involved Resident #5, and was signed by the Social Worker. Further review revealed CNA M documented (Resident #17) has turned off (Resident #5's) O2 (oxygen) concentrator during the night shift because it is to (too) loud and she has an go up and took off her nasal cannula and put it in her drawer beside her bed when (Resident #5) does not get up out of bed as she does have a bed alarm. Further review revealed the SW documented, Findings: 3 concerns on this issue - SW spoke with Resident on [DATE] when concerns were submitted. Resident admitted to removing O2 cannula because Resident wasn't using it and turning the O2 concentrator off because it was too noisy and she couldn't sleep. Resolution: SW advised Resident (#17) that she is endangering her roommate (Resident #5). Resident (#17) became tearful and stated she would no longer turn the O2 concentrator off. Resident (#17) to be moved to another room ASAP. Resident (#17) advised she would be moving and agreed to do so. (signed by the SW). During an interview on [DATE] at 09:10 AM Resident #5 could not recall any incidents regarding her use of oxygen. During an interview on [DATE] at 08:50 Resident #17 did not want to participate in an interview regarding her previous roommate. During an interview on [DATE] at 08:50 Resident #5 could not participate in an interview due to confusion. An attempt to interview Resident #5's representative was unsuccessful. During a joint interview on [DATE] at 03:05 PM with the Administrator, the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the allegation of neglect and or abuse on behalf of Resident #5. ADM stated the SW had not brought the allegation to her attention. ADM stated the allegations of abuse and or neglect could have been investigated and reported to the state. A record review of the facility's undated Residents Abuse, Neglect or Mistreatment policy revealed, Policy: Each Resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse or involuntary seclusion. All facility staff shall be in-serviced upon employment and annually regarding residents right and freedom form abuse, neglect, mistreatment, and misappropriation of property. suspected or substantiated cases of Resident abuse, neglect, misappropriation of property or mistreatment shall thoroughly be investigated and documented by the administrator and reported to the appropriate state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities which involved 2 of 6 residents (Resident #8 and #24) reviewed for crushed medication administration and medication errors. 1. RN G administered Resident #8's medications: a. ranolazine 500mg extended-release tablet by crushing the tablet. Ranolazine is used to treat heart related chest pain. 2. RN G administered Resident #24's medications: a. duloxetine 30mg delayed-release capsule by opening the capsule. Duloxetine is used to treat depression and anxiety. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #8's admission record dated 10/17/2024 revealed an admission date of 10/01/2024 with diagnoses which included dysphagia oropharyngeal and pharyngoesophageal phases (difficulty swallowing, oropharyngeal airway refers to the pharynx, the hollow tube inside the neck that starts behind the nose and stops at the top of the windpipe and esophagus) as a result from a stroke. A record review of Resident #8's admission MDS assessment dated [DATE] revealed Resident #8 was an [AGE] year-old female admitted under hospice care and assessed with a BIMS score of 07 out of a possible 15 which indicated severe cognitive impairment. Further review revealed resident #8 was assessed as medically complex and had a surgery for her gastrointestinal tract . including creation . percutaneous feeding tubes (a peg-tube) and was assessed with a feeding tube. Further review revealed Resident #8 used high risk drugs which included anti-depressants. A record review of Resident #8's physicians' orders dated 10/18/2024 revealed Resident #8 was to receive crushed medications as follows, may alter meditation by crushing, opening caps, or administering in food or fluids. (Only open or crash if manufacturer allows) Further review revealed Resident #8 was prescribed ranolazine extended release 12-hour 500mg give 500mg via peg tube two times daily for antianginal (heart pain) A record review of Resident #8's October 2024 Medication Administration record revealed RN G documented she administered ranolazine extended release 12-hour 500mg give 500mg via peg tube two times daily for antianginal at 07:00 PM. A record review of The United States of America's Food and Drug Administrations website https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021526s012lbl.pdf accessed 10/18/2024 revealed, . (ranolazine) extended-release tablets - Initial U.S. Approval: 2006 ------------------------INDICATIONS AND USAGE------------------------- (Brand name ranolazine) is indicated for the treatment of chronic angina. DOSAGE AND ADMINISTRATION 2.1 Dosing Information Initiate (Brand name ranolazine) dosing at 500 mg twice daily . Take (Brand name ranolazine) with or without meals. Swallow (Brand name ranolazine) tablets whole; do not crush, break, or chew. During an observation on 10/18/2024 at 07:00 PM revealed RN G prepared and administered to Resident #8 ranolazine 500mg one tablet extended release by crushing the tablet and administering the medication via Resident #8's indwelling a Peg tube. 2. A record review of Resident #24's admission record dated 10/17/2024 revealed an admission date of 03/31/2023 with diagnoses which included Parkinson's disease with dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk). A record review of Resident #24's annual MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female admitted for long term care under hospice services and assessed with a BIMS score of 04 out of a possible 15 which indicated severe cognitive impairment. Resident #24 was assessed with a life expectancy of less than 6 months. Further review revealed Resident #24 received antidepressant medications. A record review of Resident #24's physicians' orders dated 10/18/2024 revealed Resident #24 was to receive crushed medications as follows, may alter meditation by crushing, opening caps, or administering in food or fluids. (Only open or crash if manufacturer allows) Resident #24 was prescribed to receive a regular diet with a pureed diet and an antidepressant medication duloxetine oral capsule delayed-release sprinkle 30mg give 1 capsule two times a day for depression A record review of The United States of America's Food and Drug Administrations website https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021427s049lbl.pdf accessed 10/18/2024 revealed, . (Brand Name) (duloxetine hydrochloride) Delayed-Release Capsules for Oral Use. Initial U.S. Approval: 2004 . DOSAGE AND ADMINISTRATION----------------------- o (Brand name duloxetine) should generally be administered once daily without regard to meals. (Brand name duloxetine) should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents be sprinkled on food or mixed with liquids (2.1). 2 DOSAGE AND ADMINISTRATION (Brand name duloxetine) should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents sprinkled on food or mixed with liquids. All of these might affect the enteric coating. A record review of Resident #24's October 2024 Medication Administration record revealed RN G documented she administered duloxetine oral capsule delayed release sprinkle 30mg give 1 capsule by mouth two times a day for depression on 10/18/2024 at 07:00 PM. During an observation on 10/18/2024 at 06:50 PM revealed RN G prepared and administered to Resident #24 duloxetine 30mg 1 oral capsule by opening the capsule and mixing it with apple sauce. During an interview on 10/18/2024 at 07:05 PM RN G stated she did not recognize Resident #8's and nor Resident #24's extended-release medications and should have not crushed the medications. RN G stated extended release, delayed release medications should not be opened and or crushed. RN G stated she would report the medication errors to the DON and the medical director. During a joint interview on 10/18/2024 at 5:30 PM with the DON and ADON, the DON stated delayed release medications should not be crushed and or opened. A record review of the facility's undated Medication Error policy revealed, it is the policy of (the facility) to be free of significant medication errors and error rates. A medication error will be filled out for each medication or treatment error. medication error: federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or her health . examples are listed below : . wrong dosage form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents had orders and followed physician's orders for the resident's immediate care for 1 of 13 Residents (Resident #1) reviewed for admission orders. The facility failed to ensure Resident #1's admission orders for insulin administration and blood sugar checks were entered on admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result in a deterioration of their condition. Findings included: Record review of Resident #1's face sheet, dated [DATE], reflected he was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus, Resident #1's face sheet did not list his code status. Record review of Resident #1's nursing notes revealed was admitted to the facility after dinner service on [DATE] and expired on [DATE] around midnight. Record review of Resident #1'admission assessment dated [DATE] reflected he had intact cognition. Record review of Resident #1's clinical record revealed a care plan was not available. Record review of Resident #1's physician orders, dated [DATE], did not contain any orders for insulin or blood glucose checks. Record review of Resident #1's hospital Discharge summary, dated [DATE], reflected discharge orders for regular insulin 70/30 U-100 100 unit/mL, 45 units subcutaneous QHS (every night at bedtime) PRN (as needed). The paperwork highlighted the order and showed it was next due at bedtime as needed takes if glucose if greater than 150. Record review of Resident #1's hospital clinicals MAR from [DATE] showed his bedside glucose (reference normal ranges 70-110) readings as 307, 380, 136, 133, and 124. The MAR reflected he received insulin twice at the hospital on [DATE] and [DATE]. Record review of Resident #1's facility MAR and vitals, dated [DATE], for [DATE] revealed his blood glucose was never checked. During an interview on [DATE] at 12:35 p.m. LVN I stated she did recall Resident #1 had a leg amputation and she obtained his vitals. LVN, I stated resident orders should be put in prior to the residents arrival but stated she was not responsible for putting the orders in the DON at the time would have put in the orders. LVN, I did take the report from the hospital about the resident. LVN, I stated she could not recall if the DON was there during her shift that day. During an interview on [DATE] at 11:41 a.m. attempts to reach the previous DON by phone were unsuccessful. The previous DON resigned from the facility in January of 2024. During an interview on [DATE] at 1:55 p.m. the Administrator stated the resident would come with orders from the hospital. The administrator stated she recalled she spoke to LVN I and asked her what happened with his admission orders. The administrator stated LVN I would have been responsible for putting in Resident #1's admission orders. The administrator stated she did not think the previous DON was there at the time Resident #1 was admitted . Record review of the facility's Medication Administration, policy undated, indicated purpose to accurately prepare, administer and document oral medications .remember any medications that need vital signs taken before being given and take them and hold the medication if necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 (RN K) of 13 nurses reviewed for competent nursing care. RN K failed to administer Resident #12's 10-235 mg hydrocodone acetaminophen one hour before or after the scheduled time according to the facility's policy. These deficient practices could places residents at risk of not receiving medications timely . The findings included: Record review of Resident #12's face sheet, dated 9/7/24, revealed an [AGE] year-old female was admitted on [DATE], with diagnosis that included Parkinson's disease with dyskinesia with fluctuations (is a progressive disorder that affects the nervous system and causes tremors, stiffness and slow movement.), migraine without aura (genetically-influenced complex neurological disorder characterized by episodes of moderate-to-severe headache, most often unilateral and generally associated with nausea and light and sound sensitivity.), spinal stenosis (the space inside the backbone is too small. This can put pressure on the spinal cord and nerves that travel through the spine), and psychotic disorder with hallucinations due to know psychological condition. Record review of Resident #12's MDS, dated [DATE], revealed the resident cognition was severely impaired. Record review of Resident #12's physician orders, dated 9/7/24, revealed the resident received the following medications: *10-235 mg hydrocodone acetaminophen, give 1 tablet by mouth four times a day for pain, with a start date of 5/6/24, and no end date. Record review of Resident #12's Medication Audit Report dated 9/5/24, revealed RN K administered 10-235 mg hydrocodone acetaminophen at the following times: 8/31/24 *9:34 a.m. scheduled for 8:00 a.m. *1:30 p.m. scheduled for 12:00 p.m. *6:03 p.m. scheduled for 4:00 p.m. *7:03 p.m. scheduled for 8:00 p.m. 9/1/24 *9:46 a.m. scheduled for 8:00 a.m. *12:55 p.m. scheduled for 12:00 p.m. *6:48 p.m. scheduled for 4:00 p.m. *7:08 p.m. scheduled for 8:00 p.m. During an interview on 9/6/24 at 11:37 a.m. RN K stated she worked weekends at the facility. RN K stated many times she was too busy with residents and administering medications would pass medications to 2 or 3 residents before she documented in the MAR. RN K stated she kept a cheat sheet of what residents took what medications and wrote residents names on the medication cups. RN K stated she would put a check mark on her cheat sheet to remember she passed their medications. RN K stated she would try to give Resident #12 her 8 p.m. dose of hydrocodone before she put her to bed so she does not wake her up later. RN K stated she got sidetracked documenting the 4:00 p.m. dose she gave before dinner, documented it at 6:30 p.m., and failed to change the administration time. RN K stated the facility policy was to administer medications one hour before or after the ordered time. RN K stated if she was to administer the dose of hydrocodone too close together the resident could experience drowsiness, decreased respiration, low blood pressure, and could require naloxone (medicine that rapidly reverses opioid overdose). During an interview on 9/7/24 at 3:15 p.m. the DON stated staff should record narcotics in the narcotic count log as soon as they dispensed the medication. The DON stated staff should go room by room, check a resident MAR, then pull the medication, administer the medications to the resident, and document the administration. Record review of the facility's policy titled Narcotic Storage, no date, stated . when a narcotic is given it is immediately signed out or on the narcotic sheet . Record review of the facility's policy titled Medication Administration, no dated, stated purpose to accurately prepare, administer and document oral medications . Procedure .3. Read the label on the medication bottle as it is removed from the cart and check the label to the MAR. 4. Read the label prior to pouring the drug Read the label before returning the bottle to the cart. 7. Verify with MAR that you have poured the correct medicine .9. Document in the mar that medication was either taken or refused by the patient . document medication immediately after it was given . properly identified the resident before giving it to them . Whole tablets that are not clearly scored may not be split in half the pharmacists must be called . make it made one hour before scheduled time and one hour after.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 4 of 6 residents (Residents #10, 11, 12, and 13) reviewed for pharmacy services. 1. The facility failed to dispense the correct number of pills for Resident #10 per physician orders for diazepam (controlled medication used to treat anxiety, muscle spasms, and alcohol withdrawal). 2. The facility failed to ensure Resident #11 blister pack (packaging used for pharmaceuticals) of 5-325 mg of hydrocodone acetaminophen (medicine used to relieve moderate to severe pain.) was not tampered with and replaced with a 10-235 mg hydrocodone acetaminophen by RN K. 3. The facility failed to ensure nursing staff who documented they dispensed 10-235 mg hydrocodone acetaminophen in the narcotic count log also administered and or documented 10-235 mg hydrocodone acetaminophen in Resident #13's MAR. 21 of the 10-235 mg hydrocodone acetaminophen were not accounted for on the MAR in January of 2024. These failures could put residents at risk for pain, anxiety, misappropriation, and drug diversion. Findings included: 1. Record review of Resident #10's face sheet, dated [DATE], revealed an [AGE] year-old female was admitted on [DATE], readmitted on [DATE] with diagnoses that included urinary tract infection (infection of the urinary tract), dementia (memory issues), and cognitive communication deficit. Record review of Resident #10's MDS dated [DATE] revealed the resident cognition was several impaired and she took antianxiety medication. Record review of Resident #10's physician orders dated [DATE], revealed for the following: -1 tablet of 2 mg of diazepam by mouth at bedtime with a start date of [DATE] and an end date of [DATE]. -Give 2 mg of Diazepam by mouth at bedtime with a start date of [DATE] and an end date of [DATE]. Record review of Resident #10's [DATE] MAR reflected the resident received doses of Diazepam 2mg from [DATE] through [DATE] and [DATE] through 7/31//24. Record review of controlled substance active medication record of Diazepam for Resident #10, dated [DATE], revealed the facility received 14 tablets of 2 mg diazepam on [DATE] and to take 1 tablet at bedtime. LVN I, LNV M, and RN K signed out 2 tablets of 2 mg Diazepam on [DATE] (these were destroyed/not administered), [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. The order was for 1 tablet of 2mg diazepam to be administered. During an observation on [DATE] at 3:10 p.m. Resident #10's pharmacy label stated they received 14 tablets of 2 mg diazepam. During an interview on [DATE] at 3:10 p.m. LVN I stated she documented how many bubbles are filled on the blister package when it was received and not how many pills are in the package total. LVN I stated the package of diazepam may have been half tabs and therefore she documented she gave 2 pills each time. LVN, I stated there could have been an order change at that time and they should have placed a change of directions sticker on the package. LVN I stated they were probably half tabs or 1 mg tabs but she did not document if they were on the log. During an interview on [DATE] at 3:15 p.m. the DON stated staff should be recording the number of pills they receive from the pharmacy and write down the number of pills they are dispensing each time. The DON stated she was not aware the logs did not match the active orders, but she and the pharmacist did reviews of the logs monthly. 2. Record review of Resident #11's face sheet, dated [DATE], revealed an [AGE] year-old female was admitted on [DATE] with diagnosis that included dementia (memory issues), non-pressure chronic ulcer of right ankle with fat later exposed, and anxiety. Record review of Resident #11's MDS, dated [DATE], revealed the resident cognition was several impaired and she took opioid medication. Record review of Resident #11's physician orders, dated [DATE], revealed an order for 5-325 mg of hydrocodone acetaminophen give 0.5 tab by mouth every 6 hours as needed for pain with a start date of [DATE]. During an observation on [DATE] at 4:13 p.m. a blister package of 5-325 mg of hydrocodone acetaminophen for Resident #11 was observed. Pills #25 and #26 had broken seals that had clear tape on them. Pill #25 showed M367 and pill #26 showed M365. The pharmacy label stated a white scored oblong tablet side 1: M365 should be in the package. Record review of Resident #11's controlled substance active medication record of 5-325 mg of hydrocodone acetaminophen for Resident #11, dated [DATE], revealed directions to take one tablet by mouth every 6 hours with a quantity of 120 pills received. The log documented 60 were received. The medication was last signed out on [DATE] by LVN A. A date of [DATE] was written and crossed out with the words error written twice. During an interview on [DATE] at 11:37 a.m. RN K stated she worked over the weekend and on [DATE] she accidently administered Resident #12 the 5-325 mg hydrocodone that belonged to Resident #11. She stated Resident #12 was ordered 10-325 mg of hydrocodone-acetaminophen give 1 tab PO QID for pain. RN K stated she did not verify the name and did not document in the control log when she pulled the medication from the cart. RN K stated she realized at the end of her shift that the count was off for the narcotics, so she took one from resident #12's package of 10 mg hydrocodone and put it into Resident #11's package of 5 mg hydrocodone and taped it closed. RN K stated she only did it to one pill and did not notice or know why there were two pill spaces with broken and taped seals. RN K stated she was distracted and made the mistake. RN K stated she should have verified the pills. RN K stated she should have made a report when she realized her mistake. RN K stated if a resident received a higher dose of hydrocodone they could experience drowsiness, decreased respiration, low blood pressure, and could require naloxone (medicine that rapidly reverses opioid overdose). During an interview on [DATE] at 4:18 p.m. the DON stated she last check the narcotics on the nursing carts 2 weeks ago. The DON stated she did not notice any broken deals on the medication packages. During an interview on [DATE] at 12:12 p.m. LVN L stated she has known RN K to not be ready at the change of shift for them to count the narcotics because she needed to fix them. LVN L stated when they would count the narcotics, they were always accurate, and she never noticed any broken seals so there was no reason to report it to the DON. 3. Record review of Resident #13's face sheet, dated [DATE], revealed a [AGE] year-old female was admitted on [DATE] and readmitted on [DATE] with diagnosis that included type 2 diabetes mellitus and acquired absence of left leg below knee. Record review of Resident #13's MDS, dated [DATE], revealed the resident cognition was intact and she took opioid medication. Record review of Resident #13's MAR dated [DATE], revealed the following orders: *10-325 mg of hydrocodone acetaminophen give 2 tablets by mouth every 4 hours as needed for pain with a start date of [DATE] and an end date of [DATE]. *10-325 mg of hydrocodone acetaminophen give 1 tablet by mouth every 4 hours as needed for pain with a start date of [DATE] and an end date of [DATE]. The MAR showed the medications were administered on [DATE], [DATE], twice on [DATE], [DATE], twice on [DATE], and [DATE]. A total of 11 pills (3 administtrations of 2 5 mg tablets and 5 administrations of 1 5 mg tablet for a total of 11 pills). Record review of Resident #13's controlled substance active medication record of 10-325 mg of hydrocodone acetaminophen for dated [DATE], revealed directions to take one to two tablets by mouth every 4 hours as needed with a quantity of 60 pills received. The log documented 60 were received. Further review revealed the medication was dispensed 32 times between [DATE]-[DATE] by 5 different staff. -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by former DON -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by unknown LVN P -[DATE] 2 tablets by unknown LVN P -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 2 tablets by LVN O -[DATE] 1 tablet by LVN I -[DATE] 1 tablet by LVN I -[DATE] 1 tablet by LVN I -[DATE] 1 tablet by LVN I -[DATE] 2 tablets by uknown LVN Q Record review of a statement signed by Resident #13 on [DATE] stated I [Resident #13] have not been given the following medication [10-325 mg of hydrocodone acetaminophen] in the large quantities that have been documented as having been administered to you. At most, I have asked for, and received, only one tablet every couple of days. Resident #13 was not available for interview as she expired on [DATE]. During an interview on [DATE] at 5:00 p.m. the Administrator stated RN G had brought to her attention that former LVN N had been signing out Resident #13's hydrocodone acetaminophen numerous times. The Administrator stated RN G had notified the previous DON twice before going to the Administrator. The Administrator stated the previous DON never report the drug discrepancies to her. The Administrator stated as soon as she was notified of the concern, she reported it and began an investigation. The Administrator stated they were never able to interview LVN N again or drug test her because she never returned to the facility. The Administrator stated the previous DON had a personal relationship with LVN N and believed that was why she did not report her. The Administrator stated the previous DON had put in her notice to resign and did not return to the facility for the investigation. Record review of the facility's policy titled Narcotic Storage, no date, stated purpose to ensure that all controlled medications are accounted for and properly stored under double lock and key .3. The narcotics inventory is counted every shift with the oncoming licensed nurse . out of the off going licensed nurse . when a narcotic is given it is immediately signed out or on the narcotic sheet .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 8 (Resident #20) reviewed for abuse and neglect, in that: The facility failed to report an allegation of neglect to the State Survey Agency within 24 hours of being made by Resident #20. This deficient practice could place residents at risk of allegations not fully being investigated, and abuse, neglect, misappropriation, or exploitation. The findings included: Record review of Resident #20's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis including: spastic quadriplegic cerebral palsy (permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain), hyperlipidemia (abnormally high concentration of fats in the blood), and essential (primary) hypertension (abnormally high blood pressure). Record review of Resident #20's MDS assessment dated [DATE] revealed a BIMS score of 13, reflecting intact cognition. MDS revealed resident required one-person assist when toileting. Record review of Resident #20's Care Plan, undated, revealed the resident required extensive assistance when transferring and limited to extensive assistance with ADL's. Record review of a grievance form titled Concern Investigation/Response, date received 3/25/2023 by the DON revealed the resident stated that [CNA G] refused to help her to the RR, and the CNA said to her 'you can usually do it by yourself so why, what do you need?' and that the resident took herself to the restroom. The resolution stated, Made sure [Resident #20] was okay both physically and emotionally. Employee terminated. [Resident #20] appreciated the conclusion. The DON's signature was present at the bottom of the page. Record review of TULIP reflected no intakes reported by the facility since March 12, 2023. Interview on 9/12/2023 at 11:00 AM, Resident #20 revealed that there was a CNA a month or two ago who did not want to help her go to the restroom or get her out of bed, and told her to do it herself because she used to be able to. Resident #20 stated she did not have any other incidents like this occur and was satisfied with her care before and after this incident. Interview on 9/13/2023 at 10:25 AM, the DON stated she was not aware of when to report grievances to the state. The DON stated she told the ADM of the incident and was not aware of what occurred after reporting to the ADM. Interview on 9/14/2023 at 6:05 PM, the ADM stated she was not aware the incident needed to be reported to the state and expected the DON to report any instances or allegations of abuse and/or neglect. Interview on 9/15/2023 at 3:34 PM, the DON stated she was not aware she was the ANE coordinator and had never been informed of the change. Record review of memo provided by the Administrator dated 4/8/2023 revealed Effective immediately, [DON], will take over the duties and responsibilities of Abuse Coordinator as indicated in the [Facility] Abuse Reporting Policy. This memo is signed by the ADM. There was no signature present of the DON. Record review of facility policy titled Resident Abuse, Neglect or Mistreatment, undated, revealed suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated and documented by the administrator, and reported to the appropriate state agencies.

**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 for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #3) reviewed for care plans, in that. The facility failed to develop a care plan to support Resident #3's need for a spinal cord stimulator. These failures could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #3's admission record, dated 05/15/2023, revealed an admission date of 08/18/2023, with diagnoses which included post-laminectomy status [after a surgery to fuse some spinal vertebrae], chronic pain, and the presence of neurostimulator [a device which stimulates nerves]. A record review of Resident #3's admission MDS assessment, dated 08/24/2023, revealed Resident #3 was an [AGE] year-old female admitted for rehabilitation physical therapy after a surgery. Further review revealed Resident #3 was assessed without any mental cognition impairment as evidenced by a BIMS score of 15 out of 15. A record review of Resident #3's care plan dated 9/11/2023 did not reveal any support and/or interventions to meet Resident #3's needs for a spinal cord stimulator. A record review of Resident #3's Physician's progress note, dated 08/23/2023, revealed, chief complaint / reason for this visit; medically necessary visit to follow up Laminectomy, Constipation, and debility. History of Present Illness; patient is an [AGE] year-old female who resides at the facility .she is being seen today for initial nurse practitioner visit and follow up Laminectomy, Constipation, and disability . admission information relating to this stay; admit history - reason for admission for this stay, patient is an [AGE] year-old admitted to the facility for post Laminectomy. patient has a past medical history of hypertension, anemia, ulcerative colitis, chronic pain, depression, and anxiety. Patient had recent hospitalization for back pain and post Laminectomy. She underwent elective spinal cord stimulator implantation . post procedure continues to have severe pain and difficulties completing her activity. During an interview on 09/11/2023 at 1:25 PM, Resident #3 stated she was recovering from a surgery where she had a spinal cord stimulator implanted by her right hip / lower back. Resident #3 stated she had damaged spinal vertebra disks which were painful and had a surgery to fuse the disks to reduce the pain and improve her movement. Resident #3 stated she continued with the pain and had another surgery to implant a device which would send small electrical shocks to her spine to help manage the pain. Resident #3 stated she had a cell phone type of device which she would use to increase and/or decrease the amount of stimulation needed at any given time to reduce her pain. Resident #3 stated she believed she needed to always keep the stimulators remote control plugged into an electrical outlet. Resident #3 stated she had not had any interaction with the facility staff regarding the remote control for the implanted stimulator and some CNAs believe it to be a cell phone. During an interview on 09/11/2023 at 01:30 PM, LVN F stated she was the nurse for Resident #3. However, she was not familiar with Resident #3's care plan. LVN F stated she did not have any care instructions for Resident #3's spinal cord stimulator and referred the surveyor to the MDS nurse and/or the DON. During an interview on 09/11/2023 at 2:04 PM, RN E stated she was the nurse for Resident #3 and had assessed Resident #3 upon admission and assisted to develop the baseline care plan. RN E stated she had not assessed Resident #3 for a spinal cord stimulator and stated she had overlooked the spinal cord stimulator. RN E stated the DON was her supervisor and believed the DON was responsible for review of the baseline care plan and the comprehensive care plan. During an interview on 09/15/2023 at 03:00 PM, the DON stated she was responsible for ensuring MDS assessments were accurately completed and coordinated care plan meetings upon admission, and at a minimum quarterly. The DON stated the MDS nurse would alert her when an admission and/or quarterly MDS was completed and she [the DON] would set up a care plan meeting and then document the meeting in the Resident nursing progress notes. The DON reviewed Resident #3's care plan and recognized Resident #3 had no supports and/or nursing interventions for her spinal cord stimulator, she was not assessed with a stimulator .I will update the care plan. The DON stated she was responsible for oversight to ensure care plans were accurate, comprehensive, and timely. The DON stated residents should have a comprehensive care plan meeting with a care plan at admission, quarterly and as needed. The DON stated the failure could place residents at risk for not having their needs and or preferences met to include their need for patient educations to convey the benefits vs risk of their wishes to support their needs. During an interview on 09/15/2023 at 05:14 PM, the Administrator stated she was not involved in the residents' care plan needs. The Administrator stated the DON was responsible for the residents' care plan needs to include assessments, meetings, documentations, and reviews as needed. The Administrator stated she [the DON] did not tell me the care plans were not happening A record review of the facility's Care Plan / Comprehensive Interdisciplinary policy, dated 2005, revealed, a comprehensive care plan will be developed for each resident within seven days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a residents' medical, nursing, and psychosocial needs as identified in the comprehensive assessment . the interdisciplinary team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. the interdisciplinary team shall include: the Resident [if possible], the residents' family or the power of attorney, the social worker, the dietary supervisor, and activities staff member, the director of nursing, and any other staff pertinent to residence care at the time. the comprehensive care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. the care plan will be otherwise updated as warranted by changes in medication, treatment, or other changes in condition. Mandatory team members include a registered nurse with primary responsibility for the Resident . no you may also require additional assessment tools since according to federal interpretive guidelines, the physical, mental, and psychosocial rehabilitation therapist, activities personnel, medical social workers, dieticians, and other professionals such as developmental disability specialists and assessing the residents. As a result, you will still want the Residents' medical history and physical forms on admission, hospital discharge summary, etcetera, as indicated above, other tools and disciplines may also be needed.

Based on interviews and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 day (08/20/2023) of 90 days reviewed for nursing services, in that: The facility failed to have a registered nurse working on Sunday 08/20/2023. This failure could place residents at risk for harm by denying residents the advanced nursing skill level a registered nurse is supposed to provide. The findings included: A record review of the facility's Facility Assessment Tool dated 08/08/2023 revealed the facility's average daily census was projected to be 30-50, with an average of residents who have specialized care needs: 14 who need oxygen therapy, 1-3 residents who need a BiPaP / CPaP [BiPAP and CPAP machines have a lot in common. They both deliver positive air pressure (PAP) via a tabletop device connected to a tube and a mask], 1-7 residents who have behavioral health needs, 2-5 residents who need injectable medications, and an average of 7 residents who have hospice care needs. A record review of the facility census dated 09/11/2023 revealed 38 residents . A record review of the facility's RN Payroll report for the months of June 2023, July 2023, and August 2023 revealed on 08/20/2023 there was no RN scheduled for any shift during the 24-hour day. A record review of the facility's August 2023 nursing schedule revealed no RN scheduled for 08/20/2023. During an interview on 09/15/2023 at 03:00 PM, the DON stated she was responsible for making the RN coverage schedule and at a minimum she had an RN on the schedule for a minimum of 8 hours daily. The DON reviewed the August 2023 schedule and recognized there was no RN scheduled for 08/20/2023. The DON stated she could not explain the error and she and the Administrator were responsible for oversight of the schedule. The DON stated potential harm to the residents was possible . When asked what specific potential harm the DON stated that was difficult to speculate. During an interview on 09/15/2023 at 05:14 PM, the Administrator stated she was not involved in the development and oversight of the nursing schedules and the task was solely the DON's. The Administrator stated she was unaware the facility lacked an RN on 08/20/2023. The Administrator stated she believed she currently had sufficient nursing coverage. A record review of the facility's undated RN Coverage Requirements and Staffing Policy revealed, at a minimum, the facility must maintain a ratio (for every 24-hour period) of a registered nurse must be on site 8 consecutive hours a day, seven days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have the interdisciplinary team, review, and revise the comprehensive care plan after each assessment and quarterly, for 2 of 18 residents (Residents #23 and #138) reviewed for care plans, in that. 1. The facility failed to revise Resident #23's refusal to wear a right foot boot while in bed. 2. The facility failed to have a quarterly care plan meeting for Resident #138. These failures could have placed residents at risk for not having their needs met. The findings included: 1. A record review of Resident #23's admission record, dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes [a condition where the body does not make enough insulin, or it does not respond to it effectively. Insulin is a hormone that helps the cells use glucose (sugar) for energy. Symptoms include feeling tired, hungry, or thirsty, and passing more urine] and atherosclerosis of native arteries of right leg ulceration of ankle [a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall]. A record review of Resident #23's quarterly MDS, dated [DATE], revealed Resident #23 was an [AGE] year-old male admitted for long term care with a right leg ankle ulcer. Further review revealed Resident #23 was assessed without any mental cognition impairment as evidenced by a BIMS score of 15 out of 15. A record review of Resident #23's care plan dated [DATE] revealed, Resident #23 has an open wound to the right lateral ankle r/t Diabetes Date Initiated: [DATE] Revision on: [DATE] .Multipodus Boot to be on the right foot while in bed A record review of Resident #23's physician order dated [DATE], revealed Resident #23 was to have his legs raised above his heart when seated and wear a protective boot that corrects foot misalignments and minimizes the chance of skin breakdown, make sure resident wears multi-podis boot anytime he is in bed with the kickstand out so his foot doesn't roll laterally. During an interview on [DATE] at 12:50 PM Resident #23 stated he was supposed to wear a splint type boot on his right foot at night, but he refused to wear the boot due to comfort. Resident #23 stated he could not recall how long he had not worn the boot and stated it had been months. During an interview on [DATE] at 04:30 PM, CNA G stated she was the CNA for Resident #23. CNA G stated Resident #23 did not wear his boot while in bed. CNA G stated she was not aware Resident #23 was supposed to wear the boot while in bed. CNA G stated it had been some time since Resident #23 wore the boot, He refused to wear it. CNA G stated she believed the nurses were aware of his refusals but could not be specific to which nurse, date, and time. During an interview on [DATE] at 04:30 PM, LVN H stated Resident #23 did not wear a boot at night and had not for some time. LVN H stated she had not documented the refusals and had not reported the refusals to the DON but believed Resident #23's refusals were widely known. LVN H stated she was not familiar with Resident #23's care plan and did not participate with the care plan meetings. 2. A record review of Resident #138's admission record, dated [DATE], revealed an admission date of [DATE] with diagnoses which included major depressive disorder single episode, hemiplegia hemiparesis [partial paralysis on one side of the body that can affect the arms, legs, and facial muscles] following cerebral infarction [a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off], and acquired absence of left leg below the knee [an amputation]. A record review of Resident #138's entry MDS dated [DATE] revealed Resident #138 was a [AGE] year-old female admitted for long term care. A record review of Resident #138's BIMS Evaluation dated [DATE], revealed no mental cognition impairment as evidenced by a BIMS score of 15 out of 15. A record review of Resident #138's physician's orders summary, dated [DATE] revealed Resident #138 was ordered by her physician, on [DATE] to not receive CPR, DNR (Do Not Resuscitate). A record review of Resident #138's nursing progress notes revealed the DON documented a care plan meeting on [DATE]. A record review of Resident #138's medical record did not evidence any further care plan meeting beyond [DATE]. A record review of Resident #23's care plan did not evidence any review beyond [DATE]. During an interview on [DATE] at 11:15 AM, Resident #138 stated she could not specifically recall when she last attended a care plan meeting, maybe spring sometime. The surveyor asked Resident #138 if she had formulated an advance directive to detail if she wished to receive CPR if she was without breaths and a pulse; Resident #138 stated she wished to receive resuscitation measures, CPR, if she was without a pulse and not breathing. Resident #138 stated she once wanted to not receive CPR but has since changed her mind. Resident #138 stated no care plan meeting has occurred recently and stated if it had she would certainly request to receive CPR if needed. During an interview on [DATE] at 02:30 PM, the MDS nurse stated the facility process for care plan development was to have the admission LVN's assess residents for the baseline care plan, then the MDS nurse [herself] would assess the Resident per the RAI [Resident Assessment Instrument] and develop the MDS. The MDS nurse stated upon development of the MDS, the MDS nurse would report to the interdisciplinary team to include the DON. The MDS nurse stated the DON would review and sign the MDS and then would coordinate a care plan meeting. The MDS nurse received a report from the surveyor that a record review of Resident #138's Care plan meetings did not reveal any care plans after the [DATE] care plan meetings however there were several MDS assessments during the time from [DATE] to [DATE]. The MDS nurse stated it was her error she did not alert the DON to the need for a care plan meeting. The MDS nurse stated the DON was responsible for oversight to ensure care plan meetings occurred at a minimum every quarter. During an interview on [DATE] at 03:00 PM, the DON stated she was responsible for ensuring MDS assessments were accurately completed and coordinated care plan meetings upon admission, and at a minimum quarterly. The DON stated the MDS nurse would alert her when an admission and/or quarterly MDS was completed and she [the DON] would set up a care plan meeting and then document the meeting in the Resident nursing progress notes. The DON received a report from the surveyor that Resident #23 had an order for a splint boot for his right foot while in bed, but the resident had been refusing to wear the boot for months. The DON stated staff had not reported the refusals and or documented the refusals and the refusals were not reviewed in the care plan meeting. The DON received a report from the surveyor that Resident #138 had not had a care plan meeting since [DATE]. The DON stated she was not aware and would schedule a care plan meeting for Resident #138. The DON stated she was responsible for oversight to ensure care plans were accurate, comprehensive, and timely. The DON stated residents should have a comprehensive care plan meeting with a care plan at admission, quarterly and as needed. The DON stated the failure could place residents at risk for not having their needs and or preferences met to include their need for patient educations to convey the benefits vs risk of their wishes to support their needs. During an interview on [DATE] at 05:14 PM, the Administrator stated she was not involved in the residents' care plan needs. The Administrator stated the DON was responsible for the residents' care plan needs to include assessments, meetings, documentations, and reviews as needed. The Administrator stated she [the DON] did not tell me the care plans were not happening A record review of the facility's Care Plan / Comprehensive Interdisciplinary policy, dated 2005, revealed, a comprehensive care plan will be developed for each resident within seven days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a residents' medical, nursing, and psychosocial needs as identified in the comprehensive assessment . the interdisciplinary team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. the interdisciplinary team shall include: the Resident [if possible], the residents' family or the power of attorney, the social worker, the dietary supervisor, and activities staff member, the director of nursing, and any other staff pertinent to residence care at the time. the comprehensive care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. the care plan will be otherwise updated as warranted by changes in medication, treatment, or other changes in condition. Mandatory team members include a registered nurse with primary responsibility for the Resident . no you may also require additional assessment tools since according to federal interpretive guidelines, the physical, mental, and psychosocial rehabilitation therapist, activities personnel, medical social workers, dieticians, and other professionals such as developmental disability specialists and assessing the residents. As a result, you will still want the Residents' medical history and physical forms on admission, hospital discharge summary, etcetera, as indicated above, other tools and disciplines may also be needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 19 of 38 residents (Residents #2, #6, #10, #12, #15, #16, #17, #19, #21, #25, #26, #27, #28, #29, #30, #35, #39, #40, and #138) reviewed for pharmacy services, in that; 1. Resident #2 was administered a diabetic medication 24 minutes late by RN E on 09/13/2023. 2. Resident #6 was administered injectable insulin 1 hour and 23 minutes late by LVN D on 09/13/2023. 3. Resident #10 was administered 3 drugs, a blood thinner medication, a probiotic, and breathing treatment medication, 32 minutes late, by RN E on 09/13/2023. 4. Resident #12 was administered a stool softener medication 47 minutes late, by LVN D on 09/13/2023. 5. Resident #15 was administered 6 medications, a gastro-esophageal reflux medication, a vitamin, 2 pain relief medications, an antibiotic medication, and a mood-altering drug 58 minutes late by LVN D on 09/13/2023. 6. Resident #16 was administered a stool softener medication 25 minutes late by RN E on 09/13/2023. 7. Resident #17 was administered 2 drugs, an antihypertensive [high blood pressure] and an anti-psychotic [mood altering] medication 20 minutes late, by LVN D on 09/13/2023. 8. Resident #19 was administered 4 medications, 2 anti-depressant medications, a high blood pressure medication, and a breathing treatment medication 25 minutes late, by RN E on 09/13/2023. 9. Resident #21 was administered 3 drugs, an eye vitamin, glaucoma eye drops, and an anti-hypertensive 33 minutes late, by RN E on 09/13/2023. 10. Resident #25 was administered 2 drugs, a dementia drug and a pain relief medication 11 minutes late, by LVN D on 09/13/2023. 11. Resident #26 was administered 3 medications, a high blood pressure medication, a pain medication, and a stool softener 40 minutes late, by LVN D on 09/13/2023. 12. Resident #27 was administered 3 drugs, 2 cardiac medications and a high blood pressure medication 1 hour late on 09/13/2023. 13. Resident #28 was administered 2 drugs, a pain medication, and a high blood pressure medication 1 hour and 44 minutes late, by LVN D on 09/13/2023. 14. Resident #29 was administered 2 drugs, a cardiac medication, and a stool softener medication 37 minutes late, by RN E on 09/13/2023. 15. Resident #30 was administered an insulin medication 29 minutes late, by RN E on 09/13/2023. 16. Resident #35 was administered 3 drugs, a blood thinner medication, a cardiac medication, and a stool softener medication 2 hours and 40 minutes late minutes late, by LVN D on 09/13/2023. 17. Resident #39 was administered 2 drugs, a cerebral palsy medication and a seizure medication 2 hours and 29 minutes late, by LVN D on 09/13/2023. 18. Resident #40 was administered 2 drugs, a cardiac medication and a pain relief medication 20 minutes late, by RN E on 09/13/2023. 19. Resident #138 was administered 4 drugs, a nausea medication, an allergy medication, a blood thinner medication and a muscle pain relief medication 42 minutes late, by RN E on 09/13/2023. These failures could place residents at risk for not receiving the therapeutic effects of the medications prescribed. The findings included: 1. A record review of Resident #2's admission record, dated 09/15/2023, revealed an admission date of 12/02/2013 with diagnoses which included diabetes mellitus II [a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel]. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for long term care. Resident #2 was assessed with a BIMS score of 09 out of 15 which indicated moderate cognitive impairment. A record review of Resident #2's physician orders summary dated 09/13/2023 revealed Resident #2 was to receive metformin [a drug to help body cells use sugar from the blood] tablet, 1000 mg, give 1 tablet by mouth two times a day related to type 2 diabetes at 0800 and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #2 on 09/13/2023, 1 metformin tablet 1000 mg at 09:24 AM, 24 minutes late. 2. A record review of Resident #6's admission record, dated 09/15/2023, revealed an admission date of 08/09/2023 with diagnoses which included diabetes mellitus II [a disease in which the body has difficulty using excess sugar in the blood]. A record review of Resident #6's admission MDS dated [DATE] revealed Resident #6 was an [AGE] year-old male assessed with a BIMS score of 14 out of 15 indicating no mental cognition impairment. A record review of Resident #6's physicians order summary dated 09/13/2023 revealed Resident #6 was to receive novolog flexpen subcutaneous solution pen injector 100 unit/ml (insulin aspart) inject as per sliding scale: if 110 - 129 = 2 units; 130 - 149 = 4 units; 150 - 169 = 6 units; 170 - 200 = 8 units, subcutaneously two times a day related to type 2 diabetes mellitus twice a day at 07:30 AM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #6 on 09/13/2023, NovoLog flex pen subcutaneous solution pen injector at 08:53 AM, 1 hour and 20 minutes late. 3. A record review of Resident # 10's admission record dated 09/15/2023 revealed an admission date of 07/17/2023 with diagnoses which included hypertension [high blood pressure], cholecystitis [swelling of the gallbladder], and allergies. A record review of Resident #10's admission MDS dated [DATE] revealed Resident #10 was a [AGE] year-old female assessed with a BIMS score of 13 out of 15 which indicated intact mental cognition. A record review of Resident #10s physician order summary, dated 09/13/2023 revealed resident #10 was to receive, florastor capsule 250mg, give at 08:00 and 08:00 PM; fluticasone nasal spray, at 08:00 AM and at 08:00 PM; and Eliquis 5mg 1 tablet, give at 08:00 AM and at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #10 on 09/13/2023, fluticasone nasal spray, florastor capsule, and Eliquis 5mg at 09:32 AM, 32 minutes late. An observation and interview on 09/13/23 at 09:18 AM, revealed RN E prepared and administered to Resident #10 the following medications: Eliquis oral tablet 5 mg (apixaban); Florastor oral capsule; and Fluticasone Propionate nasal suspension. RN E stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for resident safety, and was responsible for all medication pass, wound care, and treatments for her residents. RN E stated the medications were ordered to be administered at 08:00 AM and she had until 09:00 AM to administer the medications per professional standards. RN E stated she had not reported her potential late medication administration for her halfof the facility census residents and still required more medication administrations for residents. RN E stated the potential risk for residents was they may not receive the therapeutic effects of their medications. 4. A record review of Resident #12's admission record dated 09/13/2023 revealed an admission date of 04/05/2021 with diagnoses which included constipation. A record review of Resident #12's annual MDS dated [DATE], revealed Resident #12 was an [AGE] year-old female assessed with a BIMS score of 10 out of 15 which indicated moderate mental cognition impairment. A record review of Resident #12's physician order summary, dated 09/13/2023 revealed Resident #12 was to receive senna plus 1 tablet two times a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #12 on 09/13/2023, senna plus capsule at 09:47 AM, 47 minutes late. 5. A record review of Resident #15's admission record dated 09/15/2023, revealed an admission date of 05/22/2023 with diagnoses which included gastro-esophageal reflux, chronic pain syndrome, kidney failure, and dementia. A record review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 was a [AGE] year-old female admitted for long term care. A record review of Resident #15's physician order summary dated 09/13/2023 revealed Resident #15 was to receive pantoprazole [a drug to reduce stomach acid] 40mg capsule twice a day at 08:00 AM and again at 08:00 PM; vitamin d twice a day at 08:00 Am and again at 08:00 PM; pregabalin [a drug to reduce nerve pain] twice a day at 08:00 AM and again at 08:00 PM; hydrocodone acetaminophen 7.5mg - 325mg 1 tablet twice a day at 08:00 AM and again at 08:00 PM; nitrofurantoin [an antibiotic] 1 - 100mg capsule, twice a day at 08:00 Am and again at 08:00 PM; Seroquel [a mood altering dementia drug] 1 - 50mg tablet twice a day at 08:00 AM and again at 08:00 PM; atenolol [a blood pressure medication] give 1 - 100mg tablet twice a day at 08:00 AM and again at 08:00 PM; and potassium give 1 -10mEq twice a day at 08:00 AM and Again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #15 on 09/13/2023, pantoprazole, vitamin D, pregabalin, hydrocodone acetaminophen, nitrofurantoin, Seroquel, atenolol, and potassium at 09:58 AM, 58 minutes late. 6. A record review of Resident #16's admission record, dated 09/15/2023, revealed an admission date of 07/12/2023 with diagnoses which included constipation, atrial flutter [an irregular heartbeat], and a urinary tract infection. A record review of Resident #16's admission MDS, dated [DATE], revealed Resident #16 was an [AGE] year-old female admitted for hospice services care. A record review of Resident #16's physician orders summary, dated 09/13/2023, revealed Resident #16 was to receive senna plus [a stool softener] 1 tablet twice a day at 08:00 AM and again at 08:00 PM; eliquist [a blood thinner] 5mg 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and nitrofurantoin [an antibiotic] 100mg 1 capsule twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #16 on 09/13/2023, senna plus capsule, a nitrofurantoin capsule, and an eliquist tablet at 09:25 AM, 25 minutes late. 7. A record review of Resident #17's admission record, dated 09/15/2023, revealed an admission date of 10/12/2022 with diagnoses which included hypertension [high blood pressure] and anxiety. A record review of Resident #17's quarterly MDS, dated [DATE], revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of 15 which indicated severe mental cognition impairment. A record review of Resident #17's physician's order summary, dated 09/13/2023, revealed Resident #17 was to receive metoprolol [a high blood pressure medication] 50mg twice a day at 08:00AM and again at 08:00 PM and Depakote [a medication to reduce anxiety] 125mg twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #17 on 09/13/2023, metoprolol and Depakote at 09:21 AM, 21 minutes late. 8. A record review of Resident #19's admission record, dated 09/15/2023, revealed an admission date of 03/09/2021 with diagnoses which included chronic obstructive pulmonary disease [a group of diseases that cause airflow blockage and breathing-related problems], depression, and hypertension [high blood pressure]. A record review of Resident #19's physician orders summary, dated 09/13/2023, revealed Resident #19 was to receive Symbicort [a steroid breathing treatment] aerosol 80-4.5mcg/act 2 puffs inhale orally twice a day at 08:00 AM and again at 08:00 PM; quetiapine [a mood altering medication] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; bupropion [an antidepressant] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and metoprolol [a drug to reduce blood pressure] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #19 on 09/13/2023, Symbicort 2 puffs, quetiapine 50mg, buprion 50mg, and metoprolol 50mg at 09:25 AM, 25 minutes late. 9. A record review of Resident #21's admission record revealed an admission date of 01/09/2023 with diagnoses which included glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve] and hypertension [high blood pressure]. A record review of Resident #21's quarterly MDS, dated [DATE], revealed Resident #21 was a [AGE] year-old female admitted for long term care with a BIMS of 11 which indicated mild cognitive impairment. A record review of Resident #21's physician orders summary dated 09/13/2023 revealed Resident #21 was to receive [NAME] vision multivitamins twice a day at 08:00 AM and again at 08:00 PM; dorzolamide optic solution 1 drop in both eyes, twice a day at 08:00 AM and again at 08:00 PM; and metoprolol [a high blood pressure medication] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #21 on 09/13/2023, pressor vision multivitamins, dorzolamide eye drops, and metoprolol at 09:33 AM, 33 minutes late. 10. A record review of Resident #25's admission record, dated 09/15/2023, revealed an admission date of 07/19/2023 with diagnoses which included dementia, and aftercare following joint replacement surgery. A record review of Resident #25's admission MDS dated [DATE], revealed Resident #25 was a [AGE] year-old female admitted for post rehab therapy. A record review of Resident #25's physician order summary, dated 09/13/2023, revealed Resident #25 was to receive Namenda [a drug used for memory loss] 10mg give 1 ablet by mouth two times a day related to dementia, at 08:00 AM and again at 08:00 PM; and Tylenol 8 Hour Tablet extended release 650mg give 1 tablet by mouth three times a day related to aftercare following joint replacement surgery at 08:00 AM, at 01:00 PM, and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #25 on 09/13/2023, Namenda and Tylenol at 09:14 AM, 14 minutes late. 11. A record review of Resident #26's admission record, dated 09/15/2023, revealed an admission date of 07/20/2023 with diagnoses which included hypertension [high blood pressure], and polyneuropathy [nerve pain] and constipation. A record review of Resident #26's admission MDS, dated [DATE], revealed Resident #26 was an [AGE] year-old male assessed with a BIMS of 11 which indicated mild cognitive impairment. A record review of resident #26's physician order summary dated 09/13/2023 revealed Resident #26 was to receive atenolol [ahigh blood pressure medication] 50mg give 1 tablet twice a day at 08:00 Am and again at 08:00 PM; acetaminophen [Tylenol] 325mg give 1 tablet twice a day at 08:00 Am and again at 08:00 PM; timoptic ophthalmic solution 0.5 % (Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma, and senna plus [a stool softener] 8.6-50mg give 1 tablet twice a day at 08:00 Am and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #26 on 09/13/2023, Tylenol, senna, and atenolol at 09:40 AM, 40 minutes late. An observation and interview on 09/13/23 at 09:30 AM revealed LVN D prepared and administered to Resident #26 the following medications: Senna Plus oral tablet 8.6-50 mg, timoptic ophthalmic solution 0.5 %, acetaminophen oral tablet 325 mg, and atenolol oral tablet 50. LVN D stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for Resident safety. LVN D stated the medications were ordered to be administered at 08:00 AM and she had until 09:00 AM to administer the medications per professional standards. LVN D stated she had not reported her potential late medication administration for her half of the facility census residents and still required more medication administrations for residents. LVN D stated the potential risk for residents was they may not receive the therapeutic effects of their medications. 12. A record review of Resident # 27's admission record, dated 09/15/2023, revealed an admission date of 10/07/2022 with diagnoses which included atrial fibrillation [an irregular heartbeat] and hypertension [high blood pressure]. A record review of Resident #27's quarterly MDS dated [DATE], revealed Resident #27 was an [AGE] year-old female assessed with a BIMS of 04 out of 15 which indicated severe mental cognition impairment. A record review of Resident #27's physician order summary, dated 09/13/2023, revealed Resident #27 was to receive diltiazem [a drug for an irregular heartbeat] 180mg give 1 capsule twice a day at 08:00 AM and again at 08:00 PM; lisinopril [a drug to lower blood pressure] 20mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and Eliquis [a blood thinner] 2.5mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #25 on 09/13/2023, diltiazem 180mg, lisinopril 20mg, and Eliquis 2.5mg at 09:29 AM, 29 minutes late. 13. A record review of Resident #28's admission record, dated 09/15/2023, revealed an admission date of 02/21/2023 with diagnoses which included hypertension [high blood pressure] and anxiety. A record review of Resident #28's quarterly MDS, dated [DATE], revealed Resident #28 was a [AGE] year-old female admitted for long term hospice care. A record review of Resident #28's physician order summary, dated 09/13/2023 revealed Resident #28 was to receive gabapentin [a drug used for nerve pain relief] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and metoprolol [a drug to lower blood pressure] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #28 on 09/13/2023, gabapentin 100mg, and metoprolol 50mg at 10:43 AM, 1 hour and 43 minutes late. 14. A record review of Resident #29's admission record, dated 09/15/2023, revealed an admission date of 04/25/2023, with diagnoses which included constipation and hypertension [high blood pressure]. A record review of Resident #29's quarterly MDS, dated [DATE], revealed Resident #29 was a [AGE] year-old male assessed with a BIMS score of 14 which indicated no cognitive mental impairment. A record review of Resident #29's physician order summary dated 09/13/2023 revealed Resident #29 was to receive Colace [a stool softener] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and carvedilol [a blood pressure medication] 25mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #29 on 09/13/2023, Colace 100mg and carvedilol 25mg at 09:37 AM, 37 minutes late. 15. A record review of Resident #30's admission record dated 09/15/2023 revealed an admission date of 12/14/2022 with diagnoses which included diabetes type II [a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells]. A record review of Resident #30's Quarterly MDS dated [DATE] revealed Resident #30 was an [AGE] year-old female admitted for long term care. A record review of Resident #30's physician order summary dated 09/13/2023 revealed Resident #30 was to receive Lantus [a slow long-lasting medication to absorb high blood sugars] 100units/ml inject 15 units in the morning. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #29 on 09/13/2023, Lantus 15units at 09:29 AM, 29 minutes late. 16. A record review of Resident #35's admission record, dated 09/15/2023, revealed an admission date of 08/29/2023 with diagnoses which included cerebral infarct [a brain bleed stroke], atrial fibrillation [an irregular heartbeat], and constipation. A record review of Resident #35's admission MDS, dated [DATE], revealed Resident #35 was an [AGE] year-old female assessed with a BIMS score of 14 out of 15 indicating no mental cognition impairment. A record review of Resident #35's physician order summary dated 09/13/2023 revealed Resident #35 was to receive Eliquis [a blood thinner] 5mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; carvedilol [a drug to slow your heartbeat] 25mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; baclofen [a drug to treat muscle stiffness] 10mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and docusate sodium [a stool softener] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #35 on 09/13/2023, Eliquis 5mg, carvedilol 25mg, baclofen 10mg, and docusate 100mg at 11:41 AM, 2 hours and 41 minutes late. 17. A record review of Resident #39's admission record, dated 09/15/2023, revealed an admission date of 09/08/2023 with diagnoses which included cerebral palsy [cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles] and epilepsy [seizures]. A record review of Resident #39's admission MDS, dated [DATE], revealed Resident #39 was a [AGE] year-old female admitted for long term care. A record review of Resident #39's physician order summary, dated 09/13/2023, revealed Resident #39 was to receive gabapentin [a drug used for nerve pain relief] 250mg/ml give 15ml three times a day at 08:00 AM, at 01:00 PM, and at 08:00 PM and levetiracetam 100mg/ml give 10ml two times a day at 08:00 Am and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #39 on 09/13/2023, gabapentin 100mg/ml 15ml and levetiracetam 100mg/ml 10 ml at 10:29 AM, 1 hour and 29 minutes late. 18. A record review of Resident #40's admission record dated 09/15/2023, revealed an admission date of 09/07/2023 with diagnoses which included hypertension [ high blood pressure] and neuropathy [nerve pain]. A record review of Resident #40's admission MDS dated [DATE] revealed Resident #40 was an [AGE] year-old male admitted for long term care. A record review of Resident #40's physician order summary, dated 09/13/2023 revealed Resident #40 was to receive carvedilol [a medication which slows the heartbeat] 3.125mg give twice a day at 08:00 AM and again at 08:00 PM and gabapentin [a drug for nerve pain relief] 100mg give twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #40 on 09/13/2023, gabapentin 100mg and carvedilol 3.125mg at 09:20 AM, 20 minutes late. 19. A record review of Resident #138's admission record, dated 09/15/2023, revealed an admission date of 06/29/2023 with diagnoses which included nausea, allergies, peripheral vascular disease [is the reduced circulation of blood to a body part other than the brain or heart], and constipation. A record review of Resident #138's quarterly MDS dated [DATE] revealed Resident #23 was an [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 15 out of 15 indicating no cognitive mental impairment. A record review of Resident #138's physician order summary, dated 09/13/2023 revealed Resident #138 was to receive ondansetron [a drug for nausea] 4mg give 1 tablet by mouth before meals; Zyrtec allergy tablet 10mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; apixaban [a blood thinner] 5mg tablet give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; Colace 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and baclofen [a drug to relive muscle stiffness] 10mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #138 on 09/13/2023, ondansetron 4mg, Zyrtec 10mg, apixaban 5mg, Colace 100mg, and baclofen 10mg at 09:42 AM, 42 minutes late. During an interview on 09/15/2023 at 03:00 PM, the DON stated residents' medications were to be administered at the time the prescriber ordered the medications and could be administered 1 hour prior or 1 hour past the prescribed time per professional standards. The DON stated she was not alerted to the potential late medication pass on 09/12/2023 by any of the nurses. The DON stated the risk to residents was they may not receive the therapeutic effects of their medications as prescribed. A record review of the facility's undated Medication Error policy revealed, it is the policy of the facility to be free of significant medication errors an error rate. A medication error report will be filled out for each medication for treatment error . federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or her health . examples are listed below: omissions; unauthorized drugs; wrong dose; wrong route of administration; wrong dosage form; wrong time, including before and after meals or drugs administered 60 minutes earlier or later then the scheduled time. Any medication error must immediately be reported to the resident's attending physician, a medication error form completed, and the immediate supervisor notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 32 medication administration opportunities with 7 errors resulting in a 21.88% medication error rate, for 2 of 5 residents (Resident #10 and #26) and 2 of 2 staff Nurses (LVN D and RN E) reviewed for medication pharmacy services, in that: 1. LVN D administered 4 late medications to Resident #26. 2. RN E administered 3 late medications to Resident #10. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. A record review of Resident #26's admission record dated 09/15/2023 revealed an admission date of 07/20/2023 with diagnoses which included hypertension [high blood pressure], constipation, glaucoma [a serious eye disease that can damage the optic nerve and cause vision loss or blindness], and polyneuropathy [a condition in which multiple peripheral nerves are damaged]. A record review of Resident #26's admission MDS assessment dated [DATE] revealed Resident #26 was an [AGE] year-old male admitted from the community for long term hospice care. A record review of Resident #26's care plan dated 09/15/2023 revealed, The resident has a terminal prognosis r/t polyneuropathy . Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain . Resident #26 has impaired visual function r/t Glaucoma . A record review of Resident #26's physician order summary, dated 09/12/2023, revealed Resident #26 was to receive on 09/12/2023 at 08:00 AM the following medications: Senna Plus oral tablet 8.6-50 mg (Sennosides-Docusate Sodium) give 2 tablet by mouth two times a day related to constipation; Timoptic ophthalmic solution 0.5 % (Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma; Acetaminophen oral tablet 325 mg give 2 tablet by mouth three times a day related to polyneuropathy; and Atenolol oral tablet 50 mg give 1 tablet by mouth two times a day related to hypertension. During an observation and interview on 09/13/23 at 09:30 AM revealed LVN D prepared and administered to Resident #26 the following medications: Senna Plus oral tablet 8.6-50 mg (sennosides-docusate sodium) Give 2 tablet by mouth two times a day related to constipation . timoptic ophthalmic solution 0.5 % (Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma .acetaminophen oral tablet 325 mg give 2 tablet by mouth three times a day related to polyneuropathy . [and] atenolol oral tablet 50 mg give 1 tablet by mouth two times a day related to hypertension. LVN D stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for Resident safety. LVN D stated the medications were ordered to be administered at 08:00 AM and had until 09:00 AM to administer the medications per professional standards. LVN D stated she had not reported her potential late medication administration for her ½ of the facility census residents and still required more medication administrations for residents. LVN D stated the potential risk for residents was they may not receive the therapeutic effects of their medications. 2. A record review of Resident #10's admission record dated 09/13/2023, revealed an admission date of 07/17/2023 with diagnoses which included allergies, hypertension [high blood pressure], and cholecystitis [a painful condition that inflames your gallbladder, a small organ that stores bile, a digestive fluid]. A record review of Resident #10's admission MDS dated [DATE], revealed Resident #10 was a [AGE] year-old female assessed with a BIMS score of 13 out of 15 which indicated Resident #10 was cognitively intact. A record review of Resident #10's physician order summary, dated 09/12/2023, revealed Resident #26 was to receive on 09/12/2023 at 08:00 AM the following medications: Eliquis oral tablet 5 mg (apixaban) give 5 mg by mouth every morning and at bedtime related to essential (primary) hypertension; Florastor oral capsule (saccharomyces boulardii) give 250 mg by mouth every morning and at bedtime related to acute cholecystitis; and Fluticasone Propionate nasal suspension (Fluticasone Propionate) 2 spray in each nostril every 12 hours for allergies. During an observation and interview on 09/13/23 at 09:18 AM RN E revealed RN E prepared and administered to Resident #10 the following medications: Eliquis oral tablet 5 mg (apixaban) give 5 mg by mouth every morning and at bedtime related to essential (primary) hypertension; Florastor oral capsule (saccharomyces boulardii) give 250 mg by mouth every morning and at bedtime related to acute cholecystitis; and Fluticasone Propionate nasal suspension (Fluticasone Propionate) 2 spray in each nostril every 12 hours for allergies. RN E stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for Resident safety, and was responsible for all medication pass, wound care, and treatments for her residents. RN E stated the medications were ordered to be administered at 08:00 AM and had until 09:00 AM to administer the medications per professional standards. RN E stated she had not reported her potential late medication administration for her ½ of the facility census residents and still required more medication administrations for residents. RN E stated the potential risk for residents was they may not receive the therapeutic effects of their medications. During an interview on 09/15/2023 at 03:00 PM, the DON stated residents' medications were to be administered at the time the prescriber ordered the medications and can be administered 1 hour prior or 1 hour past the prescribed time per professional standards. The DON stated she was not alerted to the potential late medication pass on 09/12/2023 by any of the nurses. The DON stated the risk to residents was they may not receive the therapeutic effects of their medications as prescribed. A record review of the facility's undated Medication Error policy revealed, it is the policy of the facility to be free of significant medication errors an error rate. A medication error report will be filled out for each medication for treatment error . federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or her health . examples are listed below: omissions; unauthorized drugs; wrong dose; wrong route of administration; wrong dosage form; wrong time, including before and after meals or drugs administered 60 minutes earlier or later then the scheduled time. Any medication error must immediately be reported to the resident's attending physician, a medication error form completed, and the immediate supervisor notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication rooms and 1 of 38 residents (Resident #40) reviewed for medication storage, in that: 1. LVN F failed to store unadministered medications for Resident #40. 2. The facility failed to secure the medication storage room. These failures could place residents at risk for misappropriation of property and harm by not receiving the therapeutic effects of the medications prescribed by the physician. The findings included: 1. During an observation on 09/11/2023 at 09:03 AM revealed the facility sole medication storage room door was ajar and unsecured. Further observations revealed the room to be unsupervised and unattended. During an observation and interview on 09/11/2023 at 09:15 AM LVN D stated she and LVN F were the nurses on duty and the only staff with keys to the medication storage room. LVN D stated the room was unlocked and proceeded to close and lock the medication storage room door. LVN D stated the room should have been locked. LVN D stated the risk was someone could have had access to the medications. 2. A record review of Resident #40's admission record, dated 09/11/2023, revealed an admission date of 09/07/2023 with diagnoses which included depression, hypertension [high blood pressure], surgical aftercare following surgery on the digestive system, and polyneuropathy [a condition in which multiple peripheral nerves are damaged]. A record review of Resident #40's admission MDS dated [DATE], revealed Resident #40 was an [AGE] year-old male admitted from an acute care hospital for post-surgery care. A record review of Resident #40's September 2023 physician order summary revealed Resident #40, on the morning of 09/11/2023 at 08:00 AM, was to receive 4 drugs and 1 dietary supplement. The medications and supplement were, Escitalopram Oxalate Oral Tablet 20 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day related to DEPRESSION . Lisinopril Oral Tablet 2.5MG (Lisinopril) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Manuka Honey Give 1 Tbsp by mouth one time a day for Supplement . Carvedilol Oral Tablet 3.125 MG Carvedilol) Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth three times a day related to POLYNEUROPATHY. During an observation on 09/11/2023 at 11:18 AM of Resident #40's uninhabited unsupervised room revealed a bed side table with multiple pill cups atop of the table. 1 cup was empty aside from a sticky brown residue and another pill cup presented with 3 pills and 1 capsule inside, 1 oval white capsule and 3 round white pills, 1 small, 1 medium, and 1 larger than the rest. The cups were written upon with a marker [Resident #40]. During an observation and interview on 09/11/2023 at 11:50 AM LVN F stated she was Resident #40's nurse and had administered medications that morning around 08:00 AM - 09:00 AM. LVN F entered Resident #40 unoccupied unsupervised room and recognized the medications upon the bedside table. LVN F stated she was surprised because she recalled Resident #40 taking his medications. LVN F stated she must have made an oversight error and did not administer Resident #40's medications due to being distracted with Resident #40 hygiene care. LVN F stated the risk of having the pills at the bedside was Resident #40 had not received the therapeutic effects of his medication and the drugs could have been taken by someone else. LVN F identified the drugs and the residue as escitalopram, lisinopril, honey, carvedilol, and gabapentin. During an interview on 09/15/2023 at 03:00 PM the DON stated all medications should always be secured. The DON stated the medication storage room was to be secured locked when not attended. The DON stated nurses are to administer residents' drugs by witnessing the administration and are never to leave medications at the bedside. The DON stated the risk to residents was not receiving the therapeutic effects of their medication and misappropriation of their property. A record review of the facility's undated Medication Security Policies and Procedures policy revealed, Medications must be kept secured at all times . The central medication storage shall be kept locked when facility staff is not actually in or at the storage area .

Based on interviews and record reviews the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for 1 of 1 facility reviewed for QAPI performance improvements, in that; The facility failed to develop quality improvement measures and or interventions after recognizing a failure to have the resident's physician address the pharmacists monthly drug regiment review recommendations. This failure could place residents at risk for harm by not receiving the benefits of the physician and the pharmacist's review. The findings included: Record review of documents titled Consultant Pharmacist's Monthly Report for [The Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review revealed 33 residents of the 33 sampled had no interventions to support the pharmacist recommendations. Interview on 9/14/2023 at 4:13 PM, the Pharmacist stated he was contracted to review the facility's residents for medication regimen review and to attend QAPI meetings. The pharmacist stated he had made monthly pharmacy reviews to include recommendations for the residents' physicians to review. The pharmacist stated he did not provide the physicians with the pharmacy medication regimen review paperwork, and that it was the responsibility of the facility to provide the pharmacy medication regimen recommendations to the residents' physicians. The pharmacist stated he had attended QAPI meetings and could not say if the QAPI meeting produced any quality improvement interventions to ensure residents physicians were addressing his recommendations. During an interview on 9/14/2023 at 05:00 PM, the Medical Director stated he openly discussed the difficulties that have been occurring with the primary care physicians of residents not signing or reviewing the pharmacy recommendations during the QAPI meeting approximately 6 months ago. The Medical Director stated that the difficulties discussed during the QAPI meeting had continued and he believed there needed to be a system put in place where he can assist with pharmacy review. The Medical Director stated the risks associated with not reviewing or implementing pharmacy recommendations to include gradual dose reductions can vary but can include medications building up in the residents' bodies to toxic levels. During an interview on 9/14/2023 at 5:50 PM, the Administrator stated she could not recall exactly what date, but at QAPI meetings the difficulty of having residents' physicians review the pharmacists' recommendations was addressed. The Administrator could not identify what quality improvement measures were decided upon to address the failure of the resident's physician's lack of reviewing the pharmacist's recommendations. The Administrator stated she was not aware the failure was not corrected. The Administrator stated she believed the failure was addressed by the DON and the Medical Director. The Administrator stated the DON had not reported the continued failure to have resident's physician's review the pharmacist's recommendations. The Administrator stated the responsibility for ensuring QAPI interventions were decided and implemented was upon the medical director, the DON, and the pharmacist. Interview on 9/15/2023 at 4:30 PM, the DON stated there was a long-term breakdown to have residents' physicians review the pharmacist's medication regimen review. The DON stated she had been the DON since May 2023 and has had difficulty having resident's physician's sign and document rationales for the resident's pharmacist medication regimen review. The DON stated she had reported the lack of physician reviews to the Administrator and the medical director on multiple occasions and at QAPI monthly meetings. The DON stated there had been no quality improvement measures decided at the June, July, or August 2023 QAPI meetings. The DON stated she believed the pharmacist drug regiment recommendations were not submitted to the residents' physicians because the pharmacist understood the recommendations were sent by the facility, whereas the facility understood the pharmacist was responsible for sending the pharmacy medication regimen reviews. A record review of the facility's undated quality assurance and performance improvement QAPI program revealed, this facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . authority; the owner and or governing board body of our facility is ultimately responsible for the QAPI program. the governing board owner evaluates the effectiveness of itsQAPI program at least annually and presents findings to the QAPI committee. the administrator is responsible for assuring that this facilities QAPI the program complies with federal, state, and local Regulatory agency requirements. The QAPI committee reports directly to the Administrator. The QAPI plan describes the process for identifying and correcting quality deficiencies. key components of this process include: tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systemically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action performance improvement activities and revising as needed. the committee meets monthly to review reports, evaluate data, and monitor QAPI related activities and make adjustments to the plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and what, if any, action has been taken to address them, for 34 of 38 residents (Residents #1, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 33, 36, 41, 43, 44, 45, 46, 47, 48, 49) whose records were reviewed for pharmacy services. The facility failed to present the pharmacist's recommendations to the residents' physician for medication regimen review This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #1 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: paraplegia, unspecified (paralysis of the legs and lower body), epilepsy, unspecified, not intractable, without status epilepticus (disorder characterized by recurrent seizures), and radiculopathy, lumbosacral region (pain syndrome caused by compression or irritation of nerve roots in the lower back). Record review of Resident #1 MDS assessment dated [DATE] reflected a BIMS Score of 13, reflecting intact cognition. Record review of Resident #4 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Parkinson's disease (disorder of the central nervous system that affects movement), heart failure, and hypothyroidism (a condition in which the thyroid does not produce enough thyroid hormone). Record review of Resident #4 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #5 Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Presence of Cardiac Pacemaker (small electrical device used to treat when a heart is not beating regularly), Unspecified Diastolic Heart Failure (Congestive) and Dementia (the loss of cognitive functioning). Record review of Resident #5 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #6's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, Diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #6 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #7's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Acute respiratory failure (inability to breathe properly), congestive heart failure, and atrial fibrillation (an abnormal heartbeat), and long-term use of anticoagulants (blood thinners). Record review of Resident #7 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #9's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia and chronic anemia (low concentration of iron in blood). Record review of Resident #9 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #11's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's (progressive disease that destroys memory and other important mental functions), Diabetes, and heart disease. Record review of Resident #11 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #12's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, heart failure, and kidney disease. Record review of Resident #12 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #13's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, Alzheimer's disease, and diabetes. Record review of Resident #13 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #14's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's disease, and lymphedema (swelling in the arms or legs). Record review of Resident #14 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #15's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, diabetes, and kidney failure. Record review of Resident #15 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #16's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD (a group of lung diseases that block airflow and make it difficult to breathe), and myocardial infarction (blockage of blood to the heart). Record review of Resident #16 MDS, dated [DATE] reflected a BIMS of 9, reflecting moderately impaired cognition. Record review of Resident #17's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation (an abnormal heartbeat), COPD, and diabetes. Record review of Resident #17 MDS, dated [DATE] reflected a BIMS of 6, reflecting severely impaired cognition. Record review of Resident #19's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: chronic kidney disease, COPD, and dementia. Record review of Resident #19 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #20's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: cerebral palsy (permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain), hyperlipidemia (abnormally high concentration of fats in the blood), and essential (primary) hypertension (abnormally high blood pressure). Record review of Resident #20 MDS, dated [DATE] reflected a BIMS of 13, reflecting intact cognition. Record review of Resident #21's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation. Record review of Resident #21 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #22's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease and dementia. Record review of Resident #22 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #23's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes. Record review of Resident #23 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #24's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: paraplegia, calculus of kidney (small hard deposit that forms in the kidneys). Record review of Resident #24 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #25's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia. Record review of Resident #25 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #26's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: hydrocephalus (buildup of fluid deep within the brain), hypertension (high blood pressure), and polyneuropathy (malfunction of peripheral nerves). Record review of Resident #26 MDS, dated [DATE] reflected a BIMS of 11, reflecting moderately impaired cognition. Record review of Resident #28's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: senile degeneration of the brain, and Sjogren's syndrome (immune system disorder). Record review of Resident #28 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #30's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, kidney failure, and diabetes. Record review of Resident #30 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #31's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease. Record review of Resident #31 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #33's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Bacteremia (the presence of bacteria in the blood stream), and a urinary tract infection. Record review of Resident #33 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #36's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, kidney disease, and heart disease. Record review of Resident #36 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #43's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, and atrial fibrillation. Record review of Resident #43 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #44's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: recent joint replacement. Record review of Resident #44 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #45's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Sjogren's syndrome, heart failure, and installed pacemaker. Record review of Resident #45 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #46's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes, and an acquired absence of left leg below knee. Record review of Resident #47's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and diabetes. Record review of Resident #47 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #48's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, atrial fibrillation, and chronic kidney disease. Record review of Resident #49's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD, diabetes, and kidney disease. Record review of Resident #49 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of documents titled Consultant Pharmacist's Monthly Report for [Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review of pharmacy medication regimen review Note To Attending Physician/Perscriber revealed 33 residents had no interventions to support the pharmacist recommendations. Interview on 9/14/2023 at 10:30 AM, the DON stated that pharmacist recommendations were sent to the physician by the pharmacist at the end of the day after the pharmacist had finished their review of medications. The DON stated it was regular for the facility to not hear back from the physicians regarding the pharmacy medication regimen reviews. Interview on 9/14/2023 at 3:07 PM, the DON stated that ensuring pharmacy medication regimen review were sent to physicians and sent back to the facility was the shared responsibility between the DON, the MDS Nurse, and the Social Worker. The DON stated that since there is not an ADON present, the MDS Nurse and Social Worker assisted the DON in processing pharmacy medication regimen reviews. Interview on 9/14/2023 at 4:13 PM, the Pharmacist stated he was contracted to review the facility's residents for medication regimen review and to attend QAPI meetings. The pharmacist stated he had made monthly pharmacy reviews to include recommendations for the residents' physicians to review. The pharmacist stated he did not provide the physicians with the pharmacy medication regimen review paperwork, and that it was the responsibility of the facility to provide the pharmacy medication regimen recommendations to the residents' physicians. The pharmacist stated he had attended QAPI meetings and could not say if the QAPI meeting produced any quality improvement interventions to ensure residents physicians were addressing his recommendations. Interview on 9/14/2023 at 5:00 PM, the Medical Director stated he openly discussed the difficulties that have been occurring with the primary care physicians of residents not signing or reviewing the pharmacy recommendations during QAPI approximately 6 months ago. The Medical Director stated that the difficulties discussed during the QAPI meeting had continued and he believed there needed to be a system put in place where he can assist with pharmacy review. The Medical Director stated the risks associated with not reviewing or implementing pharmacy recommendations to include gradual dose reductions can vary but can include medications building up in the residents' bodies to toxic levels. Interview on 9/14/2023 at 5:50 PM, the Administrator stated she could not recall exactly what date, but at QAPI meetings, the difficulty of having residents' physicians review the pharmacists' recommendations was addressed. The Administrator could not identify what quality improvement measures were decided upon to address the failure of the resident's physician's lack of reviewing the pharmacist's recommendations. The Administrator stated she was not aware the failure was not corrected. The Administrator stated she believed the failure was addressed by the DON and the Medical Director. The Administrator stated the DON had not reported the continued failure to have resident's physician's review the pharmacist's recommendations. The ADM stated the responsibility for ensuring QAPI interventions were decided and implemented was upon the medical director, the DON, and the pharmacist. Interview on 9/15/2023 at 4:30 PM, the DON stated there was a long-term breakdown to have residents' physicians review the pharmacist's medication regimen review. The DON stated she had been the DON since May 2023 and has had difficulty having resident's physician's sign and document rationales for the resident's pharmacist medication regimen review. The DON stated that they were not aware of any adverse outcomes related to the pharmacy medication regimen reviews not being provided to the physicians. The DON stated she had reported the lack of physician reviews to the Administrator and the medical director on multiple occasions and at QAPI monthly meetings. The DON stated there had been no quality improvement measures decided at the June, July, or August 2023 QAPI meetings. The DON stated she believed the pharmacist drug regimen recommendations were not submitted to the residents' physicians because the pharmacist understood the recommendations were sent by the facility, whereas the facility understood the pharmacist was responsible for sending the pharmacy medication regimen reviews. The DON later stated the facility is ultimately responsible for sending the pharmacy medication regimen reviews to the residents' physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it was administered in a manner than enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 34 of 34 residents (Residents #1, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 33, 36, 41, 43, 44, 45, 46, 47, 48, 49) reviewed for pharmacy, nursing, and physician cooperation with Administration oversight, in that: The facility failed to present the pharmacist's recommendations to the residents' physician for medication regimen reviews for 3 reviewed monthly pharmacist recommendations (June, July, and August 2023). This failure placed residents at risk for significant health status declines. The findings included: Record review of Resident #1 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: paraplegia, unspecified (paralysis of the legs and lower body), epilepsy, unspecified, not intractable, without status epilepticus (disorder characterized by recurrent seizures), and radiculopathy, lumbosacral region (pain syndrome caused by compression or irritation of nerve roots in the lower back). Record review of Resident #1 MDS assessment dated [DATE] reflected a BIMS Score of 13, reflecting intact cognition. Record review of Resident #4 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Parkinson's disease (disorder of the central nervous system that affects movement), heart failure, and hypothyroidism (a condition in which the thyroid does not produce enough thyroid hormone). Record review of Resident #4 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #5 Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Presence of Cardiac Pacemaker (small electrical device used to treat when a heart is not beating regularly), Unspecified Diastolic Heart Failure (Congestive) and Dementia (the loss of cognitive functioning). Record review of Resident #5 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #6's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, Diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #6 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #7's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Acute respiratory failure (inability to breathe properly), congestive heart failure, and atrial fibrillation (an abnormal heartbeat), and long-term use of anticoagulants (blood thinners). Record review of Resident #7 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #9's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia and chronic anemia (low concentration of iron in blood). Record review of Resident #9 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #11's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's (progressive disease that destroys memory and other important mental functions), Diabetes, and heart disease. Record review of Resident #11 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #12's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, heart failure, and kidney disease. Record review of Resident #12 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #13's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, Alzheimer's disease, and diabetes. Record review of Resident #13 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #14's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's disease, and lymphedema (swelling in the arms or legs). Record review of Resident #14 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #15's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, diabetes, and kidney failure. Record review of Resident #15 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #16's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD (a group of lung diseases that block airflow and make it difficult to breathe), and myocardial infarction (blockage of blood to the heart). Record review of Resident #16 MDS, dated [DATE] reflected a BIMS of 9, reflecting moderately impaired cognition. Record review of Resident #17's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation, COPD, and diabetes. Record review of Resident #17 MDS, dated [DATE] reflected a BIMS of 6, reflecting severely impaired cognition. Record review of Resident #19's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: chronic kidney disease, COPD, and dementia. Record review of Resident #19 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #20's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: cerebral palsy (permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain), hyperlipidemia (abnormally high concentration of fats in the blood), and essential (primary) hypertension (abnormally high blood pressure). Record review of Resident #20 MDS, dated [DATE] reflected a BIMS of 13, reflecting intact cognition. Record review of Resident #21's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation. Record review of Resident #21 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #22's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease and dementia. Record review of Resident #22 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #23's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes. Record review of Resident #23 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #24's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: paraplegia, calculus of kidney (small hard deposit that forms in the kidneys). Record review of Resident #24 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #25's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia. Record review of Resident #25 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #26's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: hydrocephalus (buildup of fluid deep within the brain), hypertension (high blood pressure), and polyneuropathy (malfunction of peripheral nerves). Record review of Resident #26 MDS, dated [DATE] reflected a BIMS of 11, reflecting moderately impaired cognition. Record review of Resident #28's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: senile degeneration of the brain, and Sjogren's syndrome (immune system disorder). Record review of Resident #28 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #30's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, kidney failure, and diabetes. Record review of Resident #30 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #31's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease. Record review of Resident #31 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #33's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Bacteremia (the presence of bacteria in the blood stream), and a urinary tract infection. Record review of Resident #33 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #36's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, kidney disease, and heart disease. Record review of Resident #36 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #43's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, and atrial fibrillation. Record review of Resident #43 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #44's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: recent joint replacement. Record review of Resident #44 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #45's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Sjogren's syndrome, heart failure, and installed pacemaker. Record review of Resident #45 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #46's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes, and an acquired absence of left leg below knee. Record review of Resident #47's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and diabetes. Record review of Resident #47 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #48's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, atrial fibrillation, and chronic kidney disease. Record review of Resident #49's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD, diabetes, and kidney disease. Record review of Resident #49 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of documents titled Consultant Pharmacist's Monthly Report for [Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review of pharmacy medication regimen review Note To Attending Physician/Perscriber revealed 33 residents had no interventions to support the pharmacist recommendations. Interview on 9/14/2023 at 10:30 AM, the DON stated that pharmacist recommendations are sent to the physician by the pharmacist at the end of the day after the pharmacist has finished their review of medications. The DON stated it is regular for the facility to not hear back from the physicians regarding these pharmacy medication regimen reviews. Interview on 9/14/2023 at 3:07 PM, the DON stated that ensuring pharmacy medication regimen review were sent to physicians and sent back to the facility was the shared responsibility between the DON, the MDS Nurse, and the Social Worker. The DON stated that since there is not an ADON present, the MDS Nurse and Social Worker assisted the DON in processing pharmacy medication regimen reviews. Interview on 9/14/2023 at 4:13 PM, the Pharmacist stated he was contracted to review the facility's residents for medication regimen review and to attend QAPI meetings. The pharmacist stated he had made monthly pharmacy reviews to include recommendations for the residents' physicians to review. The pharmacist stated he did not provide the physicians with the pharmacy medication regimen review paperwork, and that it was the responsibility of the facility to provide the pharmacy medication regimen recommendations to the residents' physicians. The pharmacist stated he had attended QAPI meetings and could not say if the QAPI meeting produced any quality improvement interventions to ensure residents physicians were addressing his recommendations. Interview on 9/14/2023 at 5:00 PM, the Medical Director stated he openly discussed the difficulties that have been occurring with the primary care physicians of residents not signing or reviewing the pharmacy recommendations during QAPI approximately 6 months ago. The Medical Director stated that the difficulties discussed during the QAPI meeting had continued and he believed there needed to be a system put in place where he can assist with pharmacy review. The Medical Director stated the risks associated with not reviewing or implementing pharmacy recommendations to include gradual dose reductions can vary but can include medications building up in the residents' bodies to toxic levels. Interview on 9/14/2023 at 5:50 PM, the Administrator stated she could not recall exactly what date, but at QAPI meetings the difficulty of having residents' physicians review the pharmacists' recommendations was addressed. The Administrator could not identify what quality improvement measures were decided upon to address the failure of the resident's physician's lack of reviewing the pharmacist's recommendations. The Administrator stated she was not aware the failure was not corrected. The Administrator stated she believed the failure was addressed by the DON and the Medical Director. The Administrator stated the DON had not reported the continued failure to have resident's physician's review the pharmacist's recommendations. The ADM stated the responsibility for ensuring QAPI interventions were decided and implemented was upon the medical director, the DON, and the pharmacist. Interview on 9/15/2023 at 4:30 PM, the DON stated there was a long-term breakdown to have residents' physicians review the pharmacist's medication regimen review. The DON stated she had been the DON since May 2023 and has had difficulty having resident's physician's sign and document rationales for the resident's pharmacist medication regimen review. The DON stated that they were not aware of any adverse outcomes related to the pharmacy medication regimen reviews not being provided to the physicians. The DON stated she had reported the lack of physician reviews to the Administrator and the medical director on multiple occasions and at QAPI monthly meetings. The DON stated there had been no quality improvement measures decided at the June, July, or August 2023 QAPI meetings. The DON stated she believed the pharmacist drug regimen recommendations were not submitted to the residents' physicians because the pharmacist understood the recommendations were sent by the facility, whereas the facility understood the pharmacist was responsible for sending the pharmacy medication regimen reviews. The DON later stated the facility is ultimately responsible for sending the pharmacy medication regimen reviews to the residents' physician.

Based on interviews and record reviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include: All personnel, including managers, staff as well as their education and/or training and any competencies related to resident care, for 1 of 1 facility reviewed for the facility assessment, in that; The facility assessment was developed without complete assessment data and solely by the MDS nurse without training to complete the facility assessment. This failure could place residents at risk for not having their needs met. The findings included: A record review of the facility's CMS 802 Resident Matrix dated 09/11/2023 revealed the facility census to be 38 residents. A record review of the facility's facility assessment tool dated 08/01/2023, revealed Persons involved in completing assessment; Administrator: [The Administrator]; DON: [The DON]; Governing Body Rep [The Administrator]; Medical Director [The Medical Director]; Other: [The MDS nurse]. Further review revealed there were pages missing as compared to the CMS form Facility Assessment Tool. A comparison revealed the page missing was used to identify residents diagnoses and guidelines for assessment of the facility to meet those disease needs. Another page was found to be missing which had guidance for assessing the facility's ability to provide assistance with activities of everyday life. further review revealed the page with guidance foe assessing residents needs to include emergencies was missing. During an interview on 09/15/2023 at 02:30 PM the MDS nurse stated I don't remember well .but sometime late July 2023 she alone and without training was assigned the task of completing the Facility Assessment by the Administrator during the QAPI meeting. The MDS nurse stated she was given the CMS facility assessment tool and she proceeded to fill out the form by answering the questions. The MDS nurse stated, I thought the assessment was to identify the current [Resident] census, I did not realize the assessment was more than that. The MDS nurse stated she completed the form and submitted the form to the Administrator. The MDS nurse stated in some areas of the form she just forwarded data from the previous assessment for example the area of the form Persons involved in completing assessment; Administrator: [The Administrator]; DON: [The DON]; Governing Body Rep [The Administrator]; Medical Director [The Medical Director]; Other: [The MDS nurse]. The MDS nurse stated she had used the facility's schedules to answer the questions on the form regarding determine the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each residents needs. The MDS nurse stated she documented herself as a full-time employee even though she only worked 3 days of the week. The MDS nurse stated the facility had scheduled 2 nurses per the day and evening shifts and 1 nurse for the overnight shift. The MDS nurse stated she was expected to perform her MDS duties and others as assigned, for example the facility assessment, while working at 2 different facilities'. During an interview at 09/15/2023 at 03:30 PM the DON stated the MDS nurse completed the facility assessment using the previous facility assessment. The DON stated she had not provided any training for the MDS nurse to complete the facility assessment and believed the facility assessment would be the responsibility of the Administrator. During an interview on 09/15/2023 at 04:00 PM the Administrator stated the facility assessment was the responsibility of the nursing staff and had been assigned and completed by the MDS nurse. The Administrator stated she had reviewed the facility assessment and believed it to be accurate to meet the needs of the residents. the Administrator stated she believed the DON would train the MDS nurse to complete the assessment. The Administrator stated she believed the current facility assessment would support the needs of the residents. A record review of the facility's undated [The Facility] Facility Assessment Policy revealed, The requirement for the facility assessment may be found in attachment one. Purpose; the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies . attachment one . rules and regulations, also see survey and certification memos and appendix PP in the state operations manual for additional information. Facility assessment: The facility assessment must address or include: the facilities resident population including but not limited to both the number of residents and the facilities resident capacity the physical environment equipment services and other physical plant considerations that are necessary to care for this population . all personnel including manager staff and volunteers as well as their education and or training and any competencies related to resident care . a facility based and community based risk assessment utilizing an all hazards approach. attachment 2; plan for the assessment: the administrator or designated individual assigns a person to lead the facility assessment process the leader identifies and invites team members to be on the assessment team including the Administrator, representative of the governing body, medical director, and the director of nurses and considers other persons to be on the team.

Based on observations and interviews, the facility failed to maintain an infection control program to provide an environment to help prevent the development and transmission of disease and infection for 1 of 1 resident (#17) reviewed for infection control practices in that: Registered Nurse - F used an ungloved hand to retrieve a pill that fell out of the plastic medication cup when it was removed from the blister pack, then administered to the resident. This deficient practice could affect residents who receieve a medication from a blister pack requiring removal of the medication from a blister pack, thus resulting in the spread of infection. The findings were: Observation on 07/27/2022 at 8:15 AM of Registered Nurse - F retrieved a pill that fell out of the plastic medication cup when it was removed from the blister pack. The medication was a Methadone (Methadone is a powerful drug used for pain relief) pill. In an interview on 7/21/2022 at 8:15 AM Registered Nurse F,stated she had used hand gel prior to preparing the retrieval of the medication for resident #17. In an interview on 7/22/2022 at 11:45 AM the Director of Nurses (DON) stated there was no excuse for Registered Nurse - F's actions as she is aware of never touching any medication with ungloved hands. Record review of the facility policy on Medication Administration failed to state that medications should never be touched with bare hands. It failed to state what procedure to follow if a pill was dropped. The Director of Nurses stated a revision was due for several policies. The Medication Administration had no date on it.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record review of the job titled Food Services Supervisor, revised 07/2016, revealed under Qualifications, Graduation from a course in food service supervision which meets the standards established by the American Dietetic Association or a graduate of another course in food service supervision with 90 or more hours in classroom instruction with on-the-job counseling by a dietician. Record Review of Employee List dated 7/18/2022 revealed no employee listed in the Food Service Supervisor position. Record review of undated, untitled department head list revealed Food Service Supervisor position blank In an interview on 07/22/22 at 9:12 AM [NAME] C stated, we don't currently have a dietary manager. We have been without one for about 3 months or so. I know what it takes to be one, I'm thinking about doing it, but i am nervous. I like being a cook. I have 3 times a day to make these folks day and hearing that my food was good, is what i look forward to most. In an interview on 07/22/22 at 9:23AM Administrator A stated, I don't have a Dietary Manager currently. I don't know that I've been written up on that yet. I am aware I have to have one. I can't believe I paid for the previous girl to get her certification and she left. We have ads out everywhere for help in the kitchen. Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 7/22/22, revealed all residents in the facility received meals and snacks served from the kitchen.

Based on interview and record review, the facility failed to conduct regular inspection of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 5 of 5 residents reviewed for bed rails assessments. The facility failed to have a maintenance program to conduct regular inspections of the beds and bedrails to identify risks and problems. This failure could place residents with bed rails at risk of entrapment, injury, or death. The findings were: Observation on 07/22/22 at 10:34 AM revealed Resident #2 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/19/22 at 01:25 PM revealed Resident #16 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/22/22 at 10:24 AM revealed Resident #15 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/22/22 at 10:35 AM revealed resident #28 had bed rail (assist/grab bar) on both left and right side of bed in the up position. Observation on 07/21/22 at 10:37 AM revealed resident #25 had bed rail (assist/grab bar) on both left and right side of bed in the up position. In an Interview on 07/21/22 at 10:31 AM with facility Maintenance E & D stated they were not aware of monitoring any bed rails. Maintenance E states he has never done it before. In an interview on 07/22/22 at 12:33 p.m. Maintenance D stated he did not have the manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds. In an interview on 07/21/22 at 03:04 PM with Maintenance D, he stated that all resident beds were checked and that there were 4 bed rails loose. He went on to state that he tightened all 4 bed rails. In an interview on 07/21/22 at 04:00 PM with Administrator, she states that they do not have a policy where each bed rail is checked preventatively. When asked if they have a preventative maintenance program or anything that would ensure the bed rails are checked and the frequency at which they are checked, she replied no we don't, but we should. In an interview with the Minimum Data Set Coordinator on 07/21/22 at 04:37 PM, she stated the term restraint was used for bed rails. She added the facility is not using bed rails as a restraint device. The bedrails are used as assist devices for the resident's ability to move in the bed or assist to get in or out of bed. In an interview on 7/22/2022 at 9:15 AM, the two maintenance employees (E and D) who work jointly in the facility stated they had not been checking the bed rails for safety to assure the bedrails were not loose. There was no set routine to inspect the bed rails. The two maintenance employees (E and D) who work jointly in the facility stated they did not know if the manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds were still available. In an interview on 7/22/2022 at 10:40 AM., the Administrator stated the beds in the facility came with the enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and to hang the bed remote control on. The Administrator stated if the enabler bars were ¼ bars then they would be considered bed rails, but they were enabler bars. The Administrator did not state how the facility monitors the enabler bars (assist/grab bars/bed rails) to ensure they are correctly installed on the bed. Record review of U.S. Department of Health and Human Services Food and Drug Administration (FDA) Center for Devices and Radiological Health's Guidance for Industry and FDA Staff Hospital Bed System Dimensional and assessment Guidance to Reduce Entrapment issued 3/10/2006, pages 13-17, revealed the space between the bed rail and mattress was a potential zone of entrapment. The FDA is recommending a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside surface of the rail and the compressed mattress. Record review of the facility's undated policy Use of Siderails revealed Each resident shall be provided with a hospital type bed which includes two side rails, both in good working order. The resident has the right to be free from any siderail device which would restrict their freedom of movement imposed for purposes of discipline or staff convenience and not required to treat medical condition Whenever a siderail is used as a restrain, the nursing staff will determine through a comprehensive written assessment, that the siderails are necessary to assist the resident in attaining or maintaining their highest practical physical, mental and psychosocial wellbeing the same procedures will be followed for siderails that are followed as previously mentioned for the restraints. The facility had no policy for bed safety to address checking of bedrails on a routine basis.