**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to promote and facilitate resident self- determination through support of resident choice for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to promote Resident #1's self-determination by not allowing her to eat in the dining room during meal time. This failure could place residents at risk of a decreased self-worth due to their preferences not being met. The findings include: Record Review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (affects the movement and posture) and hypertension (high blood pressure) and major depressive disorder (mood disorder that causes feelings of sadness). Record Review of Resident #1's MDS dated [DATE] revealed a BIMS score of 12. Resident #1 used a wheelchair or walker as a mobility device; Resident #1 used suitable utensils to eat on her own; however, set up assistance was needed. Record Review of Resident #1's care plan dated 3/26/2024 revealed Resident #1's goals were to improve her ability to care for herself and require less physical dependence on others with ADL's. In an interview with FM A on 10/9/2024 at 2:50pm she stated Resident#1 called her a week in a half ago, which was the end of September 2024 (unsure of actual day) and told her the nursing staff was refusing to allow her to eat her meal in the dining area. She stated Resident #1 stated she was told to eat at the nursing station or in her room because staff had called in sick and there was a shortage of staff. FM A stated she telephoned the facility and spoke with an unidentified nurse who confirmed the shortage and indicated for safety reasons all residents were to either eat in their room or at the table next to the nursing station. In an interview with CNA A at 4:23pm she stated she worked with Resident #1 for 4 days out of the week. She stated when there is staff shortage residents have to eat in their rooms or by the nursing station. She stated, Resident #1 had Covid in August 2024 (unsure of date) and was quarantined. She stated that being confined to her room with the door closed was difficult for Resident #1. During the quarantine, Resident #1 would have outbursts and began screaming, hollering, and yelling because Resident #1 was feeling like she was boxed in a small space. CNA A further stated that the boxed in feeling may have contributed to Resident #1 outburst regarding not being able to eat in the dining room. In an interview with Resident #1 on 10/9/2024 at 5:57pm she stated she wanted to eat in the dining room and not in her room. She stated she didn't like being in her room. She stated she liked being out in the area with other residents. She stated about two weeks ago a CNA pushed her in her wheelchair to the dining room where she got her tray of food. She stated the nurse came in the dining room and told her that they were short of staff, and she had to eat by the nurse's station or in her room. Resident #1 stated she didn't want to eat in her room, and she was okay where she was at. She stated she didn't have an issue eating or swallowing and she didn't want to sit at or near the nursing station to eat nor was she going in her room to eat. Resident #1 stated LVN A picked up her tray and tried to take it, but she held on to it. She stated during the struggle with the tray (both pulling on tray), the food dropped on the floor. She stated the nurse got mad and told her she had to go to her room. She stated the nurse pushed her to her room and had a CNA sat there with her. She stated another tray was brought to her room and she didn't want it. She stated a lot of times staff were not in the dining room, but they wanted to apply the rules that day. She stated every time a staff member called in sick the residents are required to eat in their rooms which is not fair. In an interview with LVN A on 10/9/2024 at 6:54pm revealed she worked with Resident #1 and has recently documented on her behavior issue. LVN A stated Resident#1 is a problem. She stated she spoke with the [NAME] employees who informed her that Resident #1 has a diminished mental capacity of a 5-year-old. LVN A stated about two weeks ago there was a CNA who called in sick and would not be in to work. She stated the call in made the shift short of staff and as a result nurses must be on the floor doing observation and were not available to be in the dining room for observation. During this time, resident are to eat either in their rooms or at the table located next to the nursing station. LVN A stated Resident#1 wanted to go to the dining room during that time and she told her she could choose to eat in her room or next to the nursing station. She stated Resident #1 was adamant about eating in the dining room. She stated Resident #1 convinced another CNA to bring her to dining room. LVN A stated a nursing staff must be in the dining room while residents are there. There was no one monitoring residents in the dining room. LVN A stated she went to grab the tray and Resident#1 knocked all the food items off the tray onto the floor. LVN A stated she told resident she could eat in her room, but she refused. LVN A stated if Resident #1 wanted to eat in her room, there were aides in the hall that could look in her room and monitor her, but they would not be by her bedside. LVN A stated CNA B was asked to sit with Resident #1 after she took her to her room. LVN A knew the resident was upset. In an interview with the Admin on 10/9/2024 at 7:11pm he stated if an employee called in sick for their work shift, then facility policy was to call a worker in to cover that shift PRN (as needed). He stated all residents have a right to eat in the dining area and being denied because of a staff shortage was unacceptable. He stated he was unaware of that process and did not know that Resident #1 was denied the right to eat in the dining room. In an interview with PCM on 10/10/2024 at 10:30am revealed she visited 10/8/2024, with Resident #1 and during that visit, Resident #1 was crying. She stated Resident #1 told her she was manhandled (forced back to her room by a LVN pushing her in the wheelchair) back to her room from the dining area after she refused to eat in her room because the facility was short of staff. PCM stated Resident #1 does not like to eat in her room. Resident #1 likes to eat in the dining room with other residents. In an interview with CNA B on 10/10/2024 at 2:31pm revealed about two weeks ago (couldn't remember exact date), earlier during lunch time she was caring for some residents in their rooms, and she heard Resident #1 screaming, then what appeared to be a crash. She was informed by LVN A, that Resident #1 didn't want to eat in her room and got upset and knocked the food and tray on the floor. She stated LVN A wheeled Resident#1 to her room so that she could decompress and calm down because she was screaming and disturbing the other residents. CNA B stated she has been informed and trained that when staff is not available or there is a shortage of staff, the dining room is closed, and residents are to eat in their rooms because there are no staff to observe the resident in case of an emergency. CNA B stated she brought Resident #1 a food tray from the dining room, and Resident#1 told her she wasn't going to eat what was in the tray because it wasn't what she ordered or had while in the dining room. CNA B stated Resident#1 continually stated to her that she needed to eat because she was losing a lot of weight. She stated she took the tray back, told LVN A Resident #1 didn't want to eat what was on the tray. CNA B stated LVN A didn't say anything about the tray, so she returned the tray to the dining area and there wasn't another tray given to resident after her refusal. In an interview with an anonymous resident on 10/11/2024 at 12:22pm stated if there was a staff shortage, residents are required to eat in their rooms or at the supervisor's desk area. She stated this was not an issue for her since she liked to eat in her room anyway. However, she stated she knew Resident #1 does not like to eat in her room. In an interview with Resident #3 on 10/11/2024 at 12:42pm she stated, when there is a shortage of staff because staff member calls in and stated they would not be in for their work shift, residents are required to eat in their room or in the area where the nurse station is located. She stated the residents have no other choice. She stated she didn't mine eating in her room but knows Resident #1 does not like it because she liked eating in the dining area. In an interview with CNA C on 10/11/2024 at 3:45pm revealed when the facility is short staffed sometimes residents must eat in their rooms or in the area of the nursing station so if there is an issue with choking or something then the nurses can address it immediately. She stated this is only an issue with Resident #1 because she always wants her way. Record review of the facility's Resident Rights Policy dated 2/2017 and revised 10/2022 revealed, the community should educate, encourage, and honor the rights of those we serve. The Community will promote the exercise rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Record Review of the facility's Quality of Life policy dated 0/2017 and revised 1/2023 revealed: Dignity - Community will promote care of residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his individuality. Self-determination and participation. Resident has a right to: C. Make choices about aspect of life in the community that are significant to them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to recognize the residents right to formulate an advance directive for 1 of 20 residents (Resident #264) reviewed for advanced directives. The facility failed to enter a code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) for Resident #264 from admission on [DATE] to 3/21/24. This failure could place residents at risk of not having their end of life wishes met. Findings include: Record review of Resident #264's face sheet printed 3/19/24 at 2:54pm, revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of fracture of left femur, fracture of left wrist, wedge compression fracture of lumbar vertebrae, fracture of left forearm, dyspnea (shortness of breath), acute kidney failure (kidneys are not filtering correctly), type 2 diabetes (body does not produce enough insulin), and dementia. Under Advance Directive on the care plan, it was blank. Record review of Resident #264's Entry MDS assessment dated [DATE] revealed she admitted to the facility on [DATE] from a hospital. Record review of Resident #264's BIMs score performed by the SW on 3/7/24 at 4:21pm, revealed she had severely impaired cognition. Record review of Resident #264's care plan dated 3/7/24, revealed a Focus: Resident/Family/RP does not have advanced directives and elects Full Code Status (Initiated: 3/7/24, Created: 3/7/24). Goal: Community will follow full code status (resuscitation provided when the heart stops) through review date (Initiated: 3/7/24, Created: 3/7/24, Target: 6/5/24). Interventions: Review code status at least annually and as indicated (Initiated: 3/7/24, Created: 3/7/24). Record review of Resident #264's medical record revealed a Care Plan Conference note from 3/8/24 at 11:41am from the SW. The note revealed the resident's family member decided they wanted the resident to be a full code. Record review of Resident #264's active Physician Orders by MD A on 3/19/24 at 2:52pm, revealed no orders for a code status. Record review of Resident #264's Physician Orders by MD A revealed an order from 3/21/24 at 10:23am which revealed, Full Code Clarification Order. In an interview with the SW on 3/21/24 at 9:38am, she said Staff A should have put the code status in for Resident #264 when she received the admission papers for the resident. She stated she updated the care plans once admissions entered the code status for the resident. She said the nursing staff and all staff should have caught the issue and she did not know why it was not caught. She said she would investigate the issue that she had the care plan meeting, which said the resident wanted to be full code, but nothing was entered into the chart after that. In an interview with Staff A on 3/21/24 at 9:47am, she said nursing received all the admission papers from the hospital regarding code status and entered the code status. She said she was medical records and did not receive admission papers prior to the resident coming to the facility. She said admissions would be the person who would receive the paperwork before the resident arrived. In an interview with the Admissions Director on 3/21/24 at 9:51am, she said she received all the admission papers from the hospital before residents arrived. She then filled out a paper that indicated if the resident wanted to be a full code or DNR. She said then the SW had the care plan meeting and confirmed with the family/resident if the code status was correct, or if they wanted to change it. She said after the SW confirms the code status, she updated the face sheet. As far as entering the code status order, she thought nursing was responsible for that, but she was unsure. Regarding Resident #264, she said she received admission papers that the resident wanted to be a full code and had filled out the necessary papers. She said she performed all of her job duties and it was next in the hands of the SW. In an interview with the DON on 3/21/24 at 10:16am, she said the nursing staff would have received the admission papers for Resident #264 before she arrived at the facility. The nursing staff were responsible for updating the face sheet and entering a code status on the resident. She said she was unsure of why it was not done, and she would have to talk to the nurse. She said if a code status was not entered on a resident, they would perform full code until told otherwise. Record review of the facility's policy and procedure for Advanced Directives (revised January 2023) read in part: Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission .The IDT will notify the medical provider of the resident's/representative's care decisions made to include expressed advance directive, such as DNR code status. The nurse should then obtain a physician's order for appropriate care decision in order to initiate and implement the preferred treatment wishes expressed .The medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described.

**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 for 3 of 6 residents (Resident #24, Resident # 40, and Resident #213) reviewed for care plans. -Resident #24's care plan reflected she had a DNR status despite having orders to be full-code (desiring resuscitation if the heart stops) . -Resident #40's and Resident #213's care plans reflected they were a full-code status despite having orders and an active DNR on file. These failures could lead to confusion related to life saving measures, life saving measures being provided to a resident who had a DNR status, not providing life saving measures to a resident who had a full-code status. Findings included: Resident #24 Record review of Resident #24's face sheet dated 3/19/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included spinal stenosis (condition where spinal column narrows and compresses the spinal cord), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), polyneuropathy (damage to multiple peripheral nerves), scoliosis (condition characterized by sideways curvature of the spine or back bone, often noted during growth spurt just before a child attains puberty), and dementia (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #24's quarterly MDS assessment dated [DATE] with an ARD of 2/28/2024 revealed a BIMS score of 3 indicating severe impairment. The MDS documented she had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Per the MDS, Resident #24 required assistance with all ADLs except eating. The MDS revealed she was not receiving hospice care services. Record review of Resident #24's care plan dated 2/22/2024 revealed a focus on her DNR status. Record review of Resident #24's physician's orders report dated 3/19/2024 revealed an order dated 1/16/2024 for her to have a full code status. Resident #40 Record review of Resident #40's face sheet dated 3/19/2024 revealed a [AGE] year-old man admitted on [DATE]. The face sheet documented his diagnoses included acute hematogenous osteomyelitis (infection in the bone caused by bacteria or fungi) of the foot and ankle, muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (thinning of muscle mass), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (group of mental illnesses that cause constant fear and worry), neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet), hypertension (high blood pressure), heart failure (condition in which the heart has lost the ability to pump enough blood to the body's tissues), COPD (common and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), GERD (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), diverticulitis (inflammation of the diverticula, small, bulging pouches that can form in the lining of the digestive system), benign prostatic hyperplasia (condition in which the flow of urine is blocked due to the enlargement of prostate gland), and acquired absence (amputation) of the foot. Record review of Resident #40's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment. The MDS documented he had no impairment of either his upper or lower extremities, and he used a wheelchair for mobility. Per the MDS, Resident #40 required assistance with toileting, bathing, dressing his lower body, putting on and/or taking off footwear, and personal hygiene. Record review of Resident #40's care plan dated 2/15/2024 revealed a focus on his self-care deficit with interventions including assistance with bed mobility, dressing and grooming, hygiene, toileting, and transfers. The care plan revealed he did not have advanced directives in place and elected to be full code. Record review of Resident #40's DNR dated 8/31/2023 revealed it was signed by Resident #40, two witnesses, and his PCP on 8/31/2023. Record review of Resident #40's physician's orders report dated 3/19/2024 revealed an order for him to have a DNR status dated 9/8/2023. Attempted interview on 3/21/2024 at 1:24 PM with Resident #40 was unsuccessful as he refused. Attempted interview on 3/21/2024 at 3:35 PM with Resident #40 was unsuccessful as he was not in his room. Resident #213 Record review or Resident #213's face sheet revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included a pelvis (basin-shaped complex of bones that connects the trunk and the legs, supports and balances the trunk, and contains and supports the intestines, the urinary bladder, and the internal sex organs) fracture (partial or complete break in a bone), fracture of the pubis (most forward-facing bone of the pelvic bones), fracture of the fourth lumbar vertebra (bone in the lower back), hypertension (high blood pressure), and dementia (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #213's admission MDS assessment dated [DATE] with an ARD of 2/8/2024 revealed a BIMS score of 13 indicating no cognitive impairment. The MDS documented she had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Per the MDS, Resident #213 required assistance with all ADLs except eating and personal hygiene. Record review of Resident #213's care plan dated 3/16/2024 revealed she did not have advanced directives and elected to be full code. Record review of Resident #213's DNR form dated 3/8/2024 revealed it was signed by Resident #213, two witnesses, and the physician on 3/8/2024. Record review of Resident #213's physician's orders report dated 3/19/2024 revealed an order for her to have a DNR status. Interview on 3/21/2024 at 1:09 PM with Resident #213, she said she did not recall going over any paperwork when she first admitted to the facility. Resident #213 said she did not remember speaking to anyone about her advanced directives. Resident #213 said she would not want to have life saving measures provided if she required them. Interview on 3/21/2024 at 9:21 AM with the Corporate MDS Nurse, she said she was responsible for providing supervision to the MDS nurses at multiple facilities within the corporation. The Corporate MDS Nurse said updating the care plans was a system approach. The Corporate MDS Nurse said the nurse responsible for a specific area would update that care plan area, such as the nurse responsible for weights would update a resident's weight care plans. The Corporate MDS Nurse said advanced directives were typically completed by the social services department. The Corporate MDS Nurse said Resident #40's care plan was incorrect related to his DNR status. The corporate nurse said typically the social services director would update the care plan as soon as the DNR order was received from the resident's PCP. The corporate nurse said Resident #40's care plan documented he was a full-code resident, but he had an active DNR, had a DNR order, and the care plan should have reflected that. The Corporate MDS Nurse said care plan reflected her DNR on file, but the electronic medical record documented she was full code. The Corporate MDS Nurse said if a resident's advanced directives were incorrect it could lead to a miscommunication and staff either performing life saving measures on a resident who was DNR, or not providing life saving measures to a resident who was full code. Interview on 3/21/2024 at 9:29 AM with the SW, she said she had been employed for seven years. The SW said she was not responsible for updating resident care plans. The SW said she was not sure why Resident #40's care plan documented he had a full code status. The SW said Resident #40 had a DNR status. The SW said Resident #24 had gone to the hospital multiple times since her admission and her DNR or full code status may have been missed in the system. The SW said when a resident first admitted , if he/she did not have a DNR in place and wanted to do so she would complete it then. The SW said medical records would then send the DNR to the resident's PCP for signature. The SW said a resident would remain in full code status until the DNR order was received from the physician. Interview on 3/21/2024 at 10:09 AM with the DON, she said the facility had called Resident #24's RP on 3/21/2024 and the family member was confused on what a DNR entailed. The DON said Resident #24 had gone to the hospital three times since her initial DNR was put in place, and that Resident #24's RP did not understand what the difference between DNR and full code status was. The DON said Resident #24's RP had requested the facility call her prior to any life saving measures, or to send her to the hospital for life saving measures. The DON said Resident #24's RP agreed to have Resident #24 have a full code status. The DON said Resident #24's care plan was incorrect. The DON said if a resident did not have any documentation in the DNR binder, that resident was in a full code status. The DON said the facility would perform life saving measures for any resident who was full code status. The DON said the facility would complete an audit to ensure all the residents' care plans were correct regarding their advanced directives. The DON said if the resident's care plan was incorrect and noted he/she was in a full code status, the facility may begin life saving measures, but that would not be as concerning as not providing life saving measures to a resident who had a full code status. The DON said if the facility did not initiate life saving measures for a resident with a full code status, that resident could die. Interview on 3/21/2024 at 2:40 PM with the ADON, she said she had been employed since December of 2023. The ADON said her primary duties included caring for residents, advocating for residents, ensuring they were well cared for, medication administration, and assistance with ADLs. The ADON said care plans were put in place to identify a resident's care needs. The ADON said the care plans were instructions on how to care for a resident. The ADON said she would review the care plans when she had a concern for a resident. The ADON said if there were two different instructions in the care plan versus the physician's orders, she would look at order first. The ADON said if a resident was wrongly identified as having a full code status and life saving measures were provided to a resident with a DNR status, the facility or staff could be liable for damages. Interview on 3/21/2024 at 2:59 PM with the WCN, she said he had been employed since December 7, 2023. The WCN said her primary duties were to care for the residents' wounds in the building. The WCN said she was the facility's wound care nurse. The WCN said the residents' care plans provided a plan of care, or how to care for a resident at the facility. If a care plan was incorrect the resident may not receive the care he/she required. Interview on 3/21/2024 at 3:59 PM with the Admin, he said he had been employed since February 2023. The admin said his expectations related to residents' care plans were that they would ideally be completed by the IDT system. The Admin said in past communities he was employed at, the facilities would complete generalized resident care plans. The Admin said he would like for the facility to create more individualized resident care plans. The Admin said resident care plans were reviewed during the morning meetings and were completed as the IDT was able during those meetings. The Admin said his expectations for resident care plans was that they were individualized. The Admin said if a care plan did not match a resident's physician's orders, the resident may not be provided care as was ordered. The Admin said the facility ensured the physician's orders were reflected in the electronic medical record first, and then the facility would update the resident's care plan. Record review of the facility's Code Status binder revealed Resident #40's DNR was present, Resident #213's DNR was present, and Resident #24 did not have a DNR present. The binder had a list of all residents with a DNR status. Resident #40 and Resident #213 were identified as having a DNR in place, but Resident #24 was not. Record review of the facility's Care Plans policy dated February 2023 revealed a policy statement which read in part .The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . The policy documented the care plan would include any services that would not be provided due to the resident's exercise of rights, including the right to refuse treatment. Per the policy, residents had the right to refuse specific treatments. The policy noted the care plan would be updated within seven days of the completion of the comprehensive assessment. Record review of the facility's Advanced Directives policy dated January 2023 revealed a policy statement which read Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission. The policy documented that a resident's medical record and resident plan of care should reflect the resident's wishes as well as the physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 1 of 20 (Resident #48) residents sampled for ADL care. -The facility failed to provide Resident #42 with a specialized call bell between 3/19/24 and 3/21/24. -The facility failed to shower and dress Resident #42 in his own clothes between 3/19/24 and 3/21/4. -The facility failed to get Resident #42 up out of bed between 3/19/24 and 3/21/24. These failures could place residents who are dependent on staff for ADLs, at risk of not receiving personal hygiene, experiencing a delay in receiving necessary careb. Findings included: Record review of Resident #42's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admission date of 2/13/20. He had diagnoses of anoxic brain damage (brain damage from lack of oxygen), chronic heart failure (heart does not pump strongly), gastrostomy (tube into stomach for nutrition), dysphagia (unable to swallow), aphasia (unable to talk), hypertension (high blood pressure), GERD, duodenal ulcer (ulcer in the small intestine), and muscle weakness. Record review of Resident #42's Annual MDS assessment dated [DATE], revealed a BIMS was not able to be conducted. The staff assessment for mental status revealed the resident had severely impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent with all ADLs. The resident was high risk for pressure ulcers/injuries but did not have any. The MDS revealed he was receiving applications of ointments/medications other than to feet and applications of nonsurgical dressings other than to feet. He was receiving tracheostomy care while a resident. Record review of Resident #42's care plan dated 2/13/20, revealed a Focus: Resident to use Geri Chair when out of bed d/t poor trunk control (Initiated: 8/2/21, Created: 8/2/21, Revised: 4/16/22). Goal: Resident to tolerate Geri chair through next review date (Initiated: 8/2/21, Created: 8/2/21, Revised: 1/17/24). Interventions: Staff to monitor resident for safety while in Geri chair. Staff to place resident in Geri chair when out of bed for safety. Focus: The resident uses a specialized call light: Blow light (Initiated: 1/20/21, Created: 1/20/21, Revised: 1/20/21). Goal: Resident will be able to utilize my call light without noted decline; to alert care providers of my needs and wants through my next review date (Initiated: 1/20/21, Created: 1/20/21, Revised: 1/17/24). Interventions: Provide a whistle - mouth blow type call light. Round regularly to ensure needs are met. Focus: I have a self care deficit r/t cognitive impairment, poor physical functioning, incontinent of bowel and bladder (Initiated: 6/29/23, Created: 12/30/21, Revised: 6/29/23). Goal: I will maintain or improve my ability to participate in my care with ADLs through my next review date (Initiated: 12/30/21, Created: 12/30/21, Revised: 1/17/24). Interventions: Bathing/showering schedule: I prefer to be showered 2-3 times weekly & as needed. Bathing/showering care: x 2 person assistance. Bed mobility: x 2 person assistance. Dressing & grooming: x 2 person assistance. Hygiene: I require 1 staff assist for hygiene ADLs. Off-loading device: I use pressure relieving boots/devices as indicated. Toileting/incontinent care x 2 person assistance. Total lift sling size: Large/green. Total lift x 2 team members. Transfers: x 2 person assistance with Hoyer Lift. Turning & Repositioning: On rounds and as needed. Focus: The resident has a potential to skin integrity r/t needing assistance with bed mobility and incontinence of bowel and bladder (Initiated: 2/27/20, Created: 2/27/20, Revised: 2/27/20). Goal: Resident will be free from injury to skin through the review date (Initiated: 2/27/20, Created: 2/27/20, Revised: 1/17/24). Interventions: Keep skin clean and dry. Use lotion on dry skin. Record review of Resident #42's Physician Orders revealed the following orders from MD A: -Heel protectors or float heels on pillow while in bed, every shift. Ordered on 7/23/23. -The patient out of bed can be in a Geri chair. Ordered on 9/14/21. In an observation of Resident #42 on 3/19/24 at 1:44pm, the resident was laying flat on his back in bed. He was in a patient gown, was not shaved, and his hair looked greasy. He had a regular call bell pinned to the sheets and his feet were not in heel protectors or floated on pillows. In an observation of Resident #42 on 3/20/24 at 10:16am, he was laying flat on his back in bed. He had a patient gown on, was not shaved, and his hair looked greasy. He had a regular call bell pinned to the sheets and his feet were not in heel protectors or floated on pillows. In an interview with Resident #42's family member on 3/20/24 at 10:20am, she said she would come to the facility every weekend to see him. When she came, he would not be shaved, bathed, his hair was greasy, and his ears were dirty. She said she would have to clean him every weekend when she came. She said she has not been able to come for a couple months due to being sick. In an observation of Resident #42 on 3/20/24 at 3:21pm, he was laying flat on his back in bed. He had a patient gown on, was not shaved, and had greasy looking hair. He also had a regular call bell instead of a special one and his feet were not in heel protectors or floated on pillows. In an observation and interview of Resident #42 on 3/20/24 at 3:21pm, he was laying flat on his back in bed. He had a patient gown on, was not shaved, and had greasy looking hair. He also had a regular call bell instead of a special one and his feet were not in heel protectors or floated on pillows. The DON said she did not know why he was not shaved or had his special call bell. She said he would be cleaned up for tomorrow. In an observation of Resident #42 on 3/21/24 at 11:05am, he was up in a Geri chair in the activity room. He had heel protectors on, was shaved, had clean hair, and was in his normal clothes. In an interview with LVN C on 3/21/24 at 11:10am, she said she had given Resident #42 a bed bath a few days before and did not know why he was not shaved or up in his Geri chair. In an interview with the DON on 3/21/24 at 1:30pm, she said she ensured the staff were implementing the resident's interventions by making rounds throughout the day. She said the ADON and the floor nurses made rounds as well to ensure the interventions were in place. Record review of the facility's policy and procedure on Routine Resident Care (revised January 2023) read in part: Residents should receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to provide that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to maintain resident safety at all times. Licensed nurses and non-licensed direct care team members: .Showers, tub baths, and/or shampoos should be scheduled at least twice weekly and more often as needed or per residents' preferences .Daily personal hygiene minimally includes assisting .with washing their faces and hands and combing their hair. Residents should be encouraged or assisted to dress in appropriate clothing daily .Specific types of call lights, i.e. call light pads etc. should be added to the resident plan of care based upon residents abilities and limitations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #42) of 20 residents reviewed for quality of care. - The facility failed to treat Resident #42's wounds to his shins with available ointment that was prescribed. - The facility failed to treat Resident #42's tracheostomy stoma as directed by the Physician Orders. This failure could place residents at risk for diminished quality of care, pain, infection, and worsening conditions. Findings included: Record review of Resident #42's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admission date of 2/13/20. He had diagnoses of anoxic brain damage (brain damage from lack of oxygen), chronic heart failure (heart does not pump strongly), gastrostomy (tube into stomach for nutrition), dysphagia (unable to swallow), aphasia (unable to talk), hypertension (high blood pressure), GERD, duodenal ulcer (ulcer in the small intestine), and muscle weakness. Record review of Resident #42's Annual MDS assessment dated [DATE], revealed a BIMS was not able to be conducted. The staff assessment for mental status revealed the resident had severely impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent with all ADLs. The resident was high risk for pressure ulcers/injuries but did not have any. The MDS revealed he was receiving applications of ointments/medications other than to feet and applications of nonsurgical dressings other than to feet. He was receiving tracheostomy care while a resident. Record review of Resident #42's care plan dated 2/13/20, revealed a Focus: Resident has an old tracheostomy site which requires daily dressing changes (Initiated: 8/26/22, Created: 9/17/22, Revised: 9/17/22). Goal: Will have no s/sx of infection through the review date (Initiated: 8/26/22, Created: 9/17/22, Revised: 1/17/24). Interventions: Treatment as ordered. Focus: I have risk for complications r/t tracheostomy stoma (opening where tube into throat was) site causing a risk for complications or SOB (Initiated: 12/30/21, Created: 12/30/21, Revised: 4/16/22). Goal: I will have clear and equal breath sounds bilaterally through the review date (Initiated: 12/30/21, Created: 12/30/21, Revised: 1/17/24). Interventions: Provide good oral care daily and PRN. Focus: Resident has a potential for alteration in skin integrity r/t friction, immobility, and contractures (Initiated: 10/18/22, Created: 10/18/22, Revised: 10/18/22). Goal: I will maintain skin integrity through next review date (Initiated: 10/18/22, Created: 10/18/22, Revised: 1/17/24). Interventions: Observe skin while providing care, report to nurse any skin concerns noted. Take extra care when transferring, skin is fragile, use palms of hands for support when able. Record review of Resident #42's Skin and Wound Evaluation from 2/20/24 at 3:03pm, revealed the resident had a surgical incision that was present on admission and was healed. There was no mention of the wounds to both of his shins. Record review of Resident #42's progress notes revealed a note from 3/10/24 at 7:57pm from NP A which said, Cleanse trach stoma site with SNS and cotton swabs. Dry the site and cover with gauze and tape. Monitor s/s of infection and skin integrity. Record review of Resident #42's Skin & Wound-Total Body Skin Assessment from 3/12/24 at 6:40pm, revealed there were no wounds. Record review of Resident #42's Skin & Wound-Total Body Skin Assessment from 3/19/24 at 11:56pm, revealed there were no wounds. Record review of Resident #42's Physician Orders revealed the following orders from MD A: - Cleanse trach stoma site with SNS and cotton swabs. Dry stoma site with dry 4x4 gauze. Cover with gauze and tape, Every night shift. Ordered on 7/6/23. - Complete the Skin & Wound-Total Body Skin Assessment, Every night shift, every Tue for skin integrity. Ordered on 12/13/23. - Hydrocortisone Gel 1% Apply to affected areas, chest/leg topically as needed for rash/redness. Ordered 3/14/22. - Hydrocortisone Gel 1%, Apply to bilat legs/redness topically BID for redness for 14 days. Ordered on 3/20/24. Record review of Resident #42's February 2024 MAR-TAR revealed he did not receive the Hydrocortisone Gel 1% at all throughout February 2024. Record review of Resident #42's March 2024 MAR-TAR revealed it was documented that the resident received trach stoma site care from 3/14/24 to 3/20/24. The March 2024 MAR-TAR revealed the resident did not receive the Hydrocortisone Gel 1% at all from 3/14/24 to 3/20/24. Record review of Resident #42's progress notes revealed a note from the DON on 3/20/24 at 9:15pm which said, Spoke w/ NP n/o for hydrocortisone cream x 7 days/prn n/o initiated will cont to monitor. In an observation of Resident #42 on 3/19/24 at 1:44pm, he was laying on his back in bed. The resident's trach stoma was uncovered and did not have the ordered gauze on it. In an observation of Resident #42 on 3/20/24 at 10:16am, he was laying on his back in bed. The resident's trach stoma was uncovered and did not have the ordered gauze on it. In an observation of Resident #42 on 3/20/24 at 3:21pm, he was laying on his back in bed. He had deep red excoriations on both shins, from below his knee down to his ankles. In an observation and interview of Resident #42 on 3/20/24 at 4:21pm, he was laying on his back in bed. The DON observed the excoriations on the resident's shins and said the resident had a cream the nurses were using to treat it. She did not know why his trach stoma was not covered. In an observation of Resident #42 on 3/21/24 at 11:05am, he was up in a Geri chair in the activity room. The resident had his heel protectors on, and his trach stoma was covered and clean. In an interview with LVN C on 3/21/24 at 11:10AM, she said she did not see any redness or problems to Resident #42's legs and did not apply any creams to them. In an interview with the DON on 3/21/24 at 1:30pm, she said the nurses were applying the oily barrier cream instead of the steroid cream because they thought it would be better for the wounds. Record review of the facility's policy and procedure on Professional Standard of Care (revised February 2017) read in part: The community provides services that meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified). Record review of the facility's policy and procedure on Medication Administration (revised January 2023) read in part: Resident medications are administered in an accurate, safe, timely, and sanitary manner .Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route .Administer medications as ordered by the physician .Initial the electronic administration record after the medication is administered to the resident. Record review of the facility's policy and procedure on Skin and Wound Prevention and Management (revised January 2023) read in part: .At times skin failure may occur; however, the community will ensure that a resident admitting into the community will evaluated and identify the associated risks that may result in with skin breakdown .Thus, a plan of care will be developed and implemented based on the identified needs, associated risks, and current skin conditions. Each resident will receive the care and services necessary to retain or regain optimal skin integrity .Identity early onset skin breakdown so that the IDT may implement appropriate interventions as clinically indicated. Implement interventions designed to stabilize, reduce, or remove underlying risk factors. Ongoing evaluation of the plan of care and modifying or changing interventions as appropriate .The community adopts treatment protocols for the prevention, identification, assessment, and management of skin conditions, wounds, and pressure ulcer injuries .Assessment of a resident's skin condition helps determine prevention strategies. The skin assessment includes an evaluation of skin integrity. The assessment includes documentation of current pressure areas and areas of other interruption of skin integrity other than pressure. Resident's skin should be assessed/evaluated upon admission/re-admission and as clinically indicated. Clinical team members should regularly inspect each resident's skin to identify new skin concerns. A licensed nurse should at least weekly conduct a routine skin assessment/evaluation in order to identify new pressure injuries or other types of skin concerns. The licensed nurse should document the results of weekly skin checks in the resident's medical record .The licensed nurse should document the wound presentation or description of skin issue identified within the electronic health record .The licensed nurse will continue to monitor the status and progress of the wound until resolved. Should the wound deteriorate, the nurse should notify the MD/NP/PA, IDT and resident or representative of the change in condition and document the wound assessment/evaluation findings, notifications, new orders and additional interventions. Thus, the plan of care should be reviewed and updated accordingly. The nurse should continue to monitor the status of the wound and response of the treatment and interventions implemented for effectiveness and collaborate with the IDT and MD/NP/PA for any updates or concerns as identified .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 20 residents (Resident #42) reviewed for quality of care The facility failed to ensure Resident #42's interventions for his bilateral hand rolls (rolls for contractures), posey palm pad (pad in palm for contractures), and getting him up into a Geri chair (chair that helps prevent falls), were implemented. This failure could place residents at risk of a decrease in range of motion, problems with skin integrity, and decreased quality of care. Findings include: Record review of Resident #42's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admission date of 2/13/20. He had diagnoses of anoxic brain damage (brain damage from lack of oxygen), chronic heart failure (heart does not pump strongly), gastrostomy (tube into stomach for nutrition), dysphagia (unable to swallow), aphasia (unable to talk), hypertension (high blood pressure), GERD, duodenal ulcer (ulcer in the small intestine), and muscle weakness. Record review of Resident #42's Annual MDS assessment dated [DATE], revealed a BIMS was not able to be conducted. The staff assessment for mental status revealed the resident had severely impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent with all ADLs. The resident was high risk for pressure ulcers/injuries but did not have any. According to the MDS, the resident did not receive any PT/OT or restorative nursing. Record review of Resident #42's care plan dated 2/13/20, revealed a Focus: Resident to use Geri Chair when out of bed- d/t poor trunk control (Initiated: 8/2/21, Created: 8/2/21, Revised: 4/16/22). Goal: Resident to tolerate Geri Chair through next review date (Initiated: 8/2/21, Created: 8/2/21, Revised: 1/17/24). Interventions: Staff to monitor resident for safety while in Geri Chair. Staff to place resident in Geri Chair when out of bed for safety. Focus: I have a self care deficit r/t poor physical functioning (Initiated: 6/29/23, Created: 12/30/21, Revised: 6/29/23). Goal: Resident will maintain or improve ability to participate in care with ADLs through next review date (Initiated: 12/30/21, Created: 12/30/21, Revised: 1/17/24). Interventions: Offloading device: I use pressure relieving boots/devices as indicated. Place hand rolls to hands per order. Turning and repositioning: On rounds and as needed. Focus: Resident has a potential for alteration in skin integrity r/t friction, immobility and contractures (Initiated: 10/18/22, Created: 10/18/22, Revised: 10/18/22). Goal: Resident will maintain skin integrity through next review date (Initiated: 10/18/22, Created: 10/18/22, Revised: 1/17/24). Record review of Resident #42's PT Evaluation from 9/13/23 revealed he had plantar flexion contractures (unable to make foot flat) and knee extension contractures (unable to straighten knee). The evaluation recommended positioning, bed mobility, and sitting tolerance in a Geri chair. PT never received authorization from the resident's insurance to continue and was discharged from PT on 10/13/23. Record review of Resident #42's Physician Orders from MD A revealed the following orders: -Pt to wear bilateral hand rolls when in bed as tolerated or up to 8 hours daily to preserve skin and joint integrity. Ordered on 7/23/21. -The patient out of bed can be in a Geri chair. Ordered on 9/14/21. -Heel protectors or float heels on pillow while in bed, Every shift. Ordered on 7/23/23. -Posey palm pad in place Q shift. Ordered on 7/23/23. Record review of Resident #42's March 2024 MAR-TAR revealed he had received: -Heel protectors/float heels on pillow while in bed, every shift. From 3/1/24-3/21/24. -Posey palm pad in place Q shift, Every shift. From 3/1/24-3/21/24. In an observation of Resident #42 on 3/19/24 at 10:16am, he was laying on his back in bed. The resident did not have any positioning devices to his feet or hands. In an interview with Resident #42's family member on 3/19/24 at 10:20am, she said she would come up to the facility every weekend and the resident would not be bathed, shaved, or taken care of. The family member said she had been sick for the past couple of months and has not been able to come up to the facility. In an observation of Resident #42 on 3/19/24 at 1:44pm, resident was laying on his back in bed. Resident #42's roommate stated the facility never got him out of bed and did not bathe him often. There were no positioning devices on his feet or in his hands. In an observation on 3/20/24 at 3:21pm, Resident #42 was laying flat on his back in bed. There were no positioning devices to his feet and there was only 1 hand roll to his left hand. In an observation and interview of Resident #42 on 3/20/24 at 4:21pm, the DON and LVN D observed that the resident was flat on his back in bed. The resident's feet were edematous and were not in any heel protectors or floated on pillows. The resident also did not have both hand rolls or his posey palm pad in place. The DON was notified that the resident had not been out of bed in a Geri chair like recommended either. Per the DON she was not sure why these things were not in place. She said things can happen if residents were not turned. She also said anyone doing rounds could have seen the positioning devices were not on and could have put them on or turned him. She said she would ensure they would be done. In an observation of Resident #42 on 3/21/24 at 11:05am, he was up in a Geri chair in the activity room and had his heel protectors on, along with his hand rolls and posey palm pad. In an interview with LVN C on 3/21/24 at 11:10am, she said she was putting on Resident #42's boots (heel protectors to prevent pressure injury to the feet), even though there were multiple observations without them on. She did not know why he was not in his Geri chair. In an interview with the DON on 3/21/24 at 1:30pm, she said staff could see the care plans/interventions from their POCs in the EMR, and should be implementing the interventions. She said she made rounds throughout the day to make sure interventions were in place and the nurses did too. She also said the ADON made rounds as well. The DON said Resident #42 had risk factors for developing contractures due to the fact that he had a stroke. She said some of the interventions to address the risks of developing contractures were utilizing hand rolls, the boots, and an air mattress. The DON said she knew Resident #42 had bilateral hand contractures and said all staff were responsible for ensuring the devices were in place. The DON said the boots were off because the nurse had just put ointment on his legs and didn't want to put the boots back on right away. In an interview with Med Aide A on 3/21/24 at 2:15pm, she said she would check on residents every 2hrs or every 1hr if a fall risk. She said she could put the boots on and wedges in place and that these interventions would flag for them under the POC in the EMR, so they can see which resident needed what interventions. In an interview with LVN A on 3/21/24 at 2:45pm, she said she ensured the aides were implementing interventions by rounding on her residents. She said she would physically round and place eyes on her residents to ensure they were clean, showered, turned, etc. She said she would implement the interventions herself if they were not done. Record review of the facility's policy and procedure on Range of Motion (revised January 2023) read in part: The community is responsible for ensuring that residents reach and maintain their highest level of range of motion (ROM) and preventing avoidable decline of range of motion .Each resident without a limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition makes a reduction in range of motion unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 20 residents (Residents #8) reviewed for hydration. The facility failed to ensure Resident #8 received adequate fluids from 3/19/24-3/21/24. This failure could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings include: Record review of Resident #8's undated face sheet, revealed she was a [AGE] year-old female admitted on [DATE] with an original admission date of 3/1/22. She had diagnoses of polyosteoarthritis (arthritis in multiple joints), muscle wasting and atrophy, peripheral neuropathy (burning/numbness in hands/feet), hypertension (high blood pressure), atherosclerotic heart disease (plaque buildup in the heart), urine retention, atrial fibrillation (heart rate goes up and down), and a pacemaker. Record review of Resident #8's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 which indicated intact cognition. Resident #8 was independent with eating, required setup or clean-up with oral hygiene, and partial/moderate assistance with toileting and personal hygiene, showers/baths, and upper/lower body dressing. She used a wheelchair to get around the facility. According to the MDS, the resident was always continent of bowel and bladder but had obstructive uropathy (obstruction making it hard to urinate) as a diagnosis. She is at risk for pressure ulcers/injuries but did not have any. She was taking diuretics (medications that make you urinate and can dehydrate you) along with antidepressants which can cause dehydration. Record review of Resident #8's care plan dated 3/1/22, revealed a Focus: I have risk for dehydration or potential fluid deficit r/t diuretic use (Initiated: 1/20/23, Created: 3/25/22, Revised: 1/20/23). Goal: Free of symptoms of dehydration, moist mucus membranes, good skin turgor through review date (Initiated: 1/20/23, Created: 3/25/22, Revised: 1/20/23). Interventions: Monitor/document urine output for symptoms of dehydration: concentrated urine, strong odor. Monitor/document/report to MD PRN s/sx of dehydration: decreased urine output, tenting skin, cracked lips, furrowed tongue (grooves in tongue), confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, weight loss (recent/sudden). Focus: I have a self-care deficit r/t poor physical functioning, weakness & debility, incontinent of bowel & bladder, poor physical endurance (Initiated: 1/20/23, Created: 3/25/22, Revised: 1/20/23). Goal: I will maintain or improve my ability to participate in my care with ADLs through my next review date (Initiated: 1/20/23, Created: 3/25/22, Revised: 1/20/23). Interventions: Eating & drinking: I am able to feed my self and drink without physical assistance. May need to prepare my tray/foods and drinks. Mobility: I use a wheelchair. Toileting/Incontinent care x 1 person assistance. Focus: I am at risk for nutritional deficits and/or dehydration risks r/t dx: heart disease, GERD, chronic medical conditions, associated with weight variations (Initiated: 6/26/23, Created: 3/25/22, Revised: 6/26/23). Goal: I will maintain adequate fluid and nutritional status, without s/s of dehydration (Initiated: 1/20/23, Created: 3/25/22, Revised: 1/20/23). Interventions: Provide meals, snack and fluids within my dietary recommendations. Record review of Resident #8's Physician Orders revealed the following orders from MD B: -Encourage fluids, every shift. Ordered on 11/8/23. -Docusate Sodium Capsule 100mg, Give 1 capsule by mouth BID for constipation. Ordered on 1/12/23. -Senna Tablet 8.5mg, Give 1 tablet by mouth QD for constipation. Ordered 1/12/23. -Furosemide Tablet 80mg, Give 1 tablet by mouth QD for CHF. Ordered on 8/20/23. -Xiidra Ophthalmic Solution 5%, Instill 1 drop in both eyes BID for dry eyes. Ordered on 10/20/23. -Alrex Ophthalmic Suspension, Instill 2 drops in both eyes BID for dry eyes. Ordered 3/12/24. -Artificial Tears Ophthalmic Solution (Artificial Tears), Instill 1 drop in both eyes BID for dry eyes. Ordered on 3/19/24. Record review of Resident #8's March 2024 MAR-TAR revealed the resident received the following: -Furosemide 80mg from 3/1/24-3/21/24. -Alrex Ophthalmic Suspension from 3/12/24-3/21/24. -Artificial Tears from 3/19/24-3/21/24. -Docusate Sodium 100mg from 3/1/24 to 3/21/24. -Senna 8.6mg from 3/1/24 to 3/21/24. -Xiidra Ophthalmic Solution 5% from 3/1/24 to 3/21/24. In an interview and observation of Resident #8 on 3/19/24 at 1:01pm, she was sitting in a wheelchair at the foot of her bed. She said her water pitcher would not get changed for 2 days at a time. She said it was gross and she only used the water out of it to fix her hair. She said the aides would not come and fill her pitcher and she did not know who her aide was that day. The pitcher was about 1/4 full. In an interview and observation of Resident #8 on 3/21/24 at 10:59am, she was laying in bed on her back. She said she was being lazy, and her throat was kind of scratchy. She said her water pitcher still had not been refilled and it had not been refilled since the evening of 3/19/24 even though she asked a nurse to fill it. The pitcher was about 1/4 filled. She did not know the name of the nurse she asked. In an interview with LVN C on 3/21/24 at 11:10am, she said the resident's water pitchers should be filled at least once a shift. In an interview with the DON on 3/21/24 at 1:30pm, she said it was her expectation that the resident's water pitchers were filled at least once per shift. She said she could not say what could happen if they were not refilled because it depended on the resident's background and other concerns going on. In an interview with Med Aide A on 3/21/24 at 2:15pm, she said she rounded on residents every 2hrs or every 1hr if they were a fall risk. She said she filled the water pitchers up at the beginning of her shift and at the end of her shift, and at any time during her shift if the resident requested it. In an interview with CNA A on 3/21/24 at 2:22pm, she said she rounded every 30min to 2hrs depending on the resident and gets the resident's whatever they needed, including filling water pitchers. In an interview with CNA B on 3/21/24 at 2:32pm, she said she rounded on residents at least every 2hrs but usually less. She said she filled the water pitchers at least once per shift. In an interview with LVN A on 3/21/24 at 2:45pm, she said she ensured the aides did their jobs by making rounds and looking at the residents to ensure they were clean, turned, showered, etc. She said sometimes she would do the care herself if it needed to be done. In an interview with LVN B on 3/21/24 at 3:43pm, she said she ensured the aides did what they were supposed to by setting alarms for every 2hrs. Also, if she noticed the resident needed some kind of care, she would tell the aide to stop what they were doing and provide the care for the resident at that moment. Record review of the facility's policy and procedure on Certified Nurse Aide Standards of Clinical Practice (revised January 2023) read in part: Certified Nursing Assistants (CNA) should provide services and care for residents under the direction and supervision of the licensed nurse .The CNA follows the standards and procedures in the provision of services and care for residents. The CNA assists the resident in activities of daily living such as feeding, drinking .The CNA makes rounds to check each assigned resident's condition and ensure their needs are met. The CNA answer call lights promptly and assists residents as required. Record review of the facility's policy and procedure on Routine Resident Care (revised January 2023) read in part: Residents should receive the necessary assistance to maintain good grooming and personal/oral hygiene .Licensed nurses and non-licensed direct team members .Resident call lights should be answered timely and resident requests are addressed, if permitted .Bedside tables and essential items, such as a water pitcher, should be kept within reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #42) of 1 resident reviewed for gastrostomy tube management. The facility failed to follow the physician orders for Resident #42's enteral water flush (a set amount of water that is delivered into the digestive system via the feeding tube) that was ordered on 3/15/24. This failure could place residents at risk for fluid overload and nutritional deficits. Findings include: Record review of Resident #42's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with an original admission date of 2/13/20. He had diagnoses of anoxic brain damage (brain damage from lack of oxygen), chronic heart failure (heart does not pump strongly), gastrostomy (tube into stomach for nutrition), dysphagia (unable to swallow), aphasia (unable to talk), hypertension (high blood pressure), GERD, duodenal ulcer (ulcer in the small intestine), and muscle weakness. Record review of Resident #42's Annual MDS assessment dated [DATE], revealed a BIMS was not able to be conducted. The staff assessment for mental status revealed the resident had severely impaired cognition. The resident had impairment on both sides of his upper and lower extremities. According to the MDS, the resident was dependent with all ADLs. The MDS revealed the resident used a feeding tube (a tube into the stomach to receive nutrition) while a resident. He received 51% or more total calories through the feeding tube and received 500ml/day or less of fluid intake through the feeding tube. The resident was high risk for pressure ulcers/injuries but did not have any. Record review of Resident #42's care plan dated 2/13/20, revealed a Focus: The resident is at risk for nutritional deficits r/t being dependent on staff for hydration and nutrition (Initiated: 3/16/20, Created: 2/13/20, Revised: 3/16/20). Goal: Resident will maintain adequate nutritional status through review date (Initiated: 3/16/20, Created: 2/13/20, Revised: 1/17/24). Interventions: Staff to administer feeding and fluids as ordered. Provide enteral (through the intestine) feedings and flushes as recommended by my physician. Focus: The resident requires a feeding tube r/t dysphagia (trouble swallowing) causing a risk for complications (Initiated: 2/13/20, Created: 2/13/20, Revised: 8/14/20). Goal: Resident will not experience any complications associated with my feeding tube (Initiated: 2/27/20, Created: 2/27/20, Revised: 1/17/24). Interventions: Administer tube feeding per doctor's orders. RD to evaluate as indicated. Record review of Resident #42's progress notes revealed a note from the RD on 3/12/24 at 5:46pm, that revealed she recommended to decrease the free water flush from 220ml Q4hr to 160ml Q4hr to better meet the resident's fluid needs. Record review of Resident #42's Physician Orders revealed an order from MD A for the following order: - Enteral Feed Order, every 4hrs flush with 180ml water. Ordered on 3/15/24. Record review of Resident #42's March 2024 MAR-TAR revealed the staff had signed off that they had flushed the PEG tube (tube into stomach for nutrition) Q4hr with 180ml of water on 3/15/24-3/21/24. In an observation on 3/19/24 at 1:44pm, Resident #42 was laying on his back in bed. He had a feeding tube running Osmolite 1.5 (type of tube feeding formula) at 65ml/hr with water flush at 220ml Q4hr. The resident was unable to speak/communicate or move. In an observation on 3/20/24 at 10:16am, Resident #42 was asleep in bed on his back. Osmolite 1.5 (type of tube feeding formula) was running at 65ml/hr with the water flush at 220ml Q4hr. In an observation and interview on 3/20/24 at 4:21pm with the DON and LVN D, Resident #42 was laying on his back in bed with his PEG tube running and the water flush at 220ml Q4hr. The resident's feet were moderately swollen. The DON said she was not sure why the water flush would be wrong and would have to look at the orders and get back. In an interview with the DON on 3/21/24 at 10:20am, she said the reason the water flush was wrong for Resident #42 was because the order was just changed on 3/15/24. She said the nursing staff must have not seen the order. She also said she did not think anything would happen if the resident received too much fluid because G-tubers needed more water anyways. Record review of the facility's policy and procedure regarding Enteral Nutrition (revised January 25, 2022) read in part: .A resident who is fed by nasogastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasopharyngeal ulcers .The nurse checks the orders for the enteral feeding, enteral flush frequency orders for pre and post meds and free water orders for enteral nutrition/hydration .Once the tube has been placed and tube placement confirmed, the nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician .The nurse irrigates the feeding tube with the prescribed amount of water per physician to maintain or restore patency of the feeding tube and to provide free water to maintain adequate hydration of the resident. Nursing and dietary routinely monitor the following factors for evaluation of therapeutic efficacy, adverse effects, and clinical changes: weight, hydration-signs/symptoms of dehydration or overload (e.g. edema and cardiopulmonary or change in vital signs) .The resident shall be evaluated for intolerance to the enteral feeding regimen. Intolerance may be manifested by: fluid overload . [NAME]. She also said she did not think anything would happen if the resident received too much fluid because G-tubers needed more water anyways. Record review of the facility's policy and procedure regarding Enteral Nutrition (revised January 25, 2022) read in part: .A resident who is fed by nasogastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasopharyngeal ulcers .The nurse checks the orders for the enteral feeding, enteral flush frequency orders for pre and post meds and free water orders for enteral nutrition/hydration .Once the tube has been placed and tube placement confirmed, the nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician .The nurse irrigates the feeding tube with the prescribed amount of water per physician to maintain or restore patency of the feeding tube and to provide free water to maintain adequate hydration of the resident. Nursing and dietary routinely monitor the following factors for evaluation of therapeutic efficacy, adverse effects, and clinical changes: weight, hydration-signs/symptoms of dehydration or overload (e.g. edema and cardiopulmonary or change in vital signs) .The resident shall be evaluated for intolerance to the enteral feeding regimen. Intolerance may be manifested by: fluid overload .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 resident of 8 (Resident #359) observed for physical environment. The facility failed to maintain sanitary, functioning and a clean restroom for Resident #359. This failure placed the resident at risk for discomfort, infection and diminished quality of life and diminished clean, homelike environment. Findings include: Observation on 12/18/22 at 9:43 AM of Resident #359's restroom revealed dried fecal matter on the toilet seat, on the outside of the toilet bowl and on the floor near the toilet. Fecal as matter also present on the resident's shower chair. Interview on 12/18/22 at 10:15 AM Resident #359 stated she had an accident (bowel movement) in the restroom on Friday, 12/16/22. The resident stated she asked staff to clean the restroom each day since the accident. Observation on 12/18/22 at 12:08 PM of Resident #359's restroom revealed dried fecal matter still present on and around the toilet and on the shower chair . Observation on 12/19/22 at 12:10 PM of Resident #359's restroom revealed the resident's toilet and shower chair to be clean. Interview on 11/09/22 at 9:44 AM, Housekeeper A stated she just started working at the facility 2 weeks ago. She stated she started her day at 6:00 AM and was assigned to hall 100 . She stated she was told to clean room [ROOM NUMBER] right away . She stated her typical routine was that after cleaning a resident room, she would then clean the bathrooms. She stated she would clean the sink and scrub the toilet. She then pointed to the scrub brush and cleaning solution in her cart. She stated she would go back to room [ROOM NUMBER] then work her way down the hall like usual, since she was done with room [ROOM NUMBER]. Interview on 12/19/22 at 03:20 PM the Housekeeping Supervisor stated that as the supervisor, she checks resident rooms for cleanliness 2-3 times a week. Housekeeping Supervisor stated housekeepers perform light cleaning on most days, but also heavy cleaning on scheduled days for each hall. Housekeeping Supervisor stated the facility CNAs were responsible for cleaning bodily fluids of residents. Housekeeping Supervisor stated if notified, a housekeeper could go behind the CNA for a deep clean of the area. Housekeeping Supervisor stated however, the CNAs have most interaction with residents in their room and provide direct care to the residents. Interview on 12/19/22 at 3:40 PM CNA Y stated Hall 300 currently did not have a designated CNA. CNA Y stated the hall is split up among CNAs based on the number of CNAs on duty at a particular time. CNA Y stated as far as cleaning is concerned, the CNAs are responsible for ensuring the residents themselves are clean and well-kept and ensure their rooms are clean and homelike. CNA Y stated the residents' rooms were supposed to be checked for cleanliness every day. CNA Y stated ensuring resident restrooms are clean is part of the CNAs duties. CNA Y stated if she went into a resident's restroom and found feces on the toilet, or any other surface, the reasonable thing for her to do would be to clean it up at that moment. CNA Y stated if a resident informed her they had an accident and an area of their room needed cleaning, she would go ahead and clean the area also. CNA Y stated the result of feces being left on a toilet seat or shower chair could expose a resident to an unsanitary environment. Interview on 12/20/22 at 11:45 AM the DON stated the cleanliness of residents' rooms was the joint responsibility of housekeeping and CNAs. DON stated she found it hard to believe that feces was present on a resident's toilet and shower chair from Friday through Sunday. DON stated on Friday she made rounds on the 300 hall and did not come across anything out of the ordinary in any of the resident rooms. DON stated Resident #359's family also came for a visit on Friday and would have mentioned a situation like that to staff. DON stated any staff that found a resident's restroom in that condition should have cleaned the feces immediately. DON stated Resident #359 can use the restroom on her own, possibly had an accident and didn't notify the CNA on her hall when they came into her room on Sunday . DON stated the CNA could've done the initial cleaning and called housekeeping for backup cleaning and disinfecting the area. DON stated it is the CNA's responsibility to check resident rooms for cleanliness every day. DON stated resident's being exposed to feces being present on a toilet and shower chair can put them at risk for any sort of stool-borne illness. Record Review of the facility policy on Cleaning and Disinfection of Environmental Surfaces Compliance Guidelines revealed: Clean and disinfect environmental surfaces according to current CDC recommendations for disinfection of healthcare facilities . 6. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated. .8. If the spill contains large amounts of blood or body flids, the visible mater will be cleaned with disposable absorbent material/cloth, and the contaminated materials discarded in an appropriate, labeled container (biohazard). Protective gloves and other PPE appropriate for this task will be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 5% based on 2 errors out of 38 opportunities, which involved 1 of 6 residents (Resident #43) reviewed for medication errors. -LVN T did not administer Ferrous sulfate (Iron) to Resident #43 and administered one Buspirone tablet (antianxiety medication) instead of two as prescribed by the physician. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Record review of Resident #43's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: anxiety, anoxic (an absence of oxygen) brain damage, chronic systolic (congestive) heart failure, gastrostomy status (surgical opening into the stomach), and hypertension (high blood pressure). Record review of Resident #43's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. He required extensive assistance of 1-2 staff for bed mobility, dressing, eating, toilet use, and personal hygiene. He was totally dependent on two staff for transfers. Record review of Resident #43's care plan dated 12/18/22 revealed the resident took an anti-anxiety medication related to anxiety disorder as in difficulty sleeping. Interventions included: Resident #43 needed anti-anxiety medications ordered by physician. Record review of Resident #43's order summary report for December 2022 revealed the following orders: Buspirone 10 mg give 2 tablets via g-tube two times a day for anxiety, order date 9/13/22; Ferrous sulfate elixir 220 (44 Fe) mg/5 mL give 7.5 mL via PEG-tube one time a day for supplementation, order date 8/2/22. Record review of Resident #43's Licensed Nurse Administration Record for December 2022 revealed Ferrous sulfate elixir and Buspirone were scheduled for QD-M (every day - morning). In an observation and interview on 12/20/22 at 9:34 a.m. revealed LVN T prepared Resident #43's medication for administration via g-tube. She prepared Buspirone 10 mg (1 tablet), Tramadol 50 mg (1 tablet), Acetaminophen 500 mg (1 tablet), Vitamin C 500 mg (1 tablet), chewable Aspirin 81 mg (1 tablet), Cetirizine 10 mg (1 tablet), Multivitamin with minerals (1 tablet), Tizanidine 4 mg (1 tablet), Clearlax PEG 3350 17 gm, and prostat liquid. LVN T said she had 8 pills, 1 liquid (Prostat), and 1 cup of Clearlax. LVN T then prepared Lactobacillus (1 tablet) to equal a total of 9 pills, 1 liquid (Prostat), and 1 cup of Clearlax. LVN T entered Resident #43's room with 11 medication filled cups and administered them to Resident #43 via g-tube. LVN T did not administer 2 tablets of Buspirone 10 mg or 7.5 mL of Ferrous sulfate as ordered by the physician. In an interview on 12/20/22 at 10:51 a.m. LVN T said she administered one Buspirone tablet instead of two because she did not realize the order was for two tablets. She said she looked at the medication order, medication card, and checked the resident's name, medication name, dose, and directions when she prepared the medication, but said she may have been nervous. In an observation and interview on 12/20/22 at 11:00 a.m. LVN T said she did not administer Ferrous sulfate to Resident #43. She said she prepared the medications in the order listed on the eMAR but did not know how she missed the Ferrous sulfate liquid. She said there was no large risk to the patient for missing one dose of Buspirone and Ferrous sulfate. She said she would prepare and administer one additional tablet of Buspirone 10 mg and 7.5 mL of Ferrous Sulfate to Resident #43. LVN T prepared and administered Buspirone and Ferrous sulfate to Resident #43 via g-tube. In an interview on 12/20/22 at 1:59 p.m. the DON said nursing staff should use the five medication rights (right dose, medication, patient, route, and time) when administering medications. She said staff should triple check the medication orders and compare the medication blister pack to the MAR. She said to avoid omissions staff should read the MAR and compare the medication blister pack to the MAR. She said no therapeutic levels were required for the antianxiety medication Buspirone, but she would need to consult the physician to determine what to monitor for. She said she was not sure why Resident #43 was on Ferrous sulfate but said she would need to notify the physician to see if labs need to be ordered, and what to monitor for. She said it was important that residents received their medications as prescribed by the physician because there was a clinical indication for them. In an interview on 12/20/22 at 3:26 p.m. the DON said a medication error occurred when they did not follow the physician's order. She said this included improper dosage, route, and omissions. Record review of the facility's Medication Administration policy dated March 2019 reflected in part, . Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner . Responsible Disciplines Licensed Nurses, C.M.A.'s . 2. Verify the medication label against the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise the person-centered care plan to reflect current plan of care for 1 of 18 residents (Resident # 51) reviewed for Comprehensive Care Plans, in that; -Resident #51's care plan did not accurately reflect the status of her pressure wound. This failure could affect residents with wounds and placed them at risk for neglect, unmet care needs, and a decline in health. Findings included: Resident #51 Record review of Resident #51's face-sheet revealed an [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE]. She had the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting left non dominant side, dysphagia, cerebrovascular disease, type 2 diabetes, chronic pain, obesity, chronic ischemic heart disease, anemia, unspecified dementia without behavioral disturbance, hypertension, moderate protein-calorie malnutrition, muscle wasting and atrophy, lack of coordination. Record review of Resident #51's Annual MDS dated [DATE] revealed resident # 51 had a BIMS of 4 out 15 indicating severe cognitive impairment. She required extensive assistance of one person for bed mobility, eating, and toilet use. She required total assistance of two plus person for transfer. She required total assistance of one person for dressing, personal hygiene, and bathing. She was at risk of developing pressure ulcers/injuries. She had one or more unhealed pressure ulcers/injuries. She one stage 3 pressure ulcer. Record review of Resident #51's care plane with an initiated date of 6/22/2021 and a revision date of 8/12/2021 Focus pressure ulcer stage 3 to the right ankle due to history of ulcers, immobility. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness, educate resident/family/caregivers as to cause of skin breakdown. Monitor nutritional status. Monitor/document/report to MD as needed changes in skin status, appearance, color. Turn resident every 2 hours, more often as needed or requested. Record Review of Resident #51's Progress note titled skin/wound note date 9/15/2021 read in part Wound care round with Dr. Resident right ankle pressure is closed and resolved at this time. Record review of Wound evaluation and management summary dated 9/15/2021 revealed; She has a stage 3 pressure wound of the right ankle for at least 87 days duration. Prior healing wound has improved and requires confirmation of current clinical status and evaluation with preventive recommendations to prevent recurrence. Stage 3 pressure wound of the right ankle resolved on 9/15/2021. In an interview with the LVN-MDS J on 10/07/2021 at 2:24 pm, She said that Resident #51 no longer had a pressure wound and the Wound care nurse should go into the care plan and resolve the care plan when they resolve the wound. In an interview with the DON on 10/08/2021 at 10:39 am, she said Resident #51's wound should have been resolved. She said she would ask LVN-MDS J to see when it should be resolved in the care plan. In a follow up interview with the DON on 10/08/2021 at 11:55 am, she said Resident #51's wound was resolved on October 5th and they closed it out in the care plan yesterday. They try to resolve them in the care plan as soon as possible. A care plan policy was asked from the Administrator on 10/8/2021 at 12:00 pm and one was not provided at time of exit. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 695 Based on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #325) of 5 residents reviewed for respiratory care, in that: -The facility administered oxygen to Resident #325's without a physician's order. This failure placed residents who received oxygen therapy at risk of respiratory complications. Findings included: Resident #325 Record review of Resident #325's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included, COVID -19, acute respiratory failure with hypoxia, chronic atrial configuration, chronic obstructive pulmonary, atrioventricular block, and infection and inflammatory reaction due to cardiac valve prosthesis. Record review of Resident #325's 5-day MDS, dated on 09/4/21, revealed Resident #325 had a BIMS of 08, which indicated moderate cognitive impairment. Section J revealed Resident #325 had shortness of breath and trouble breathing when lying flat. Section O'' revealed oxygen therapy as a treatment for Resident #325. Record review of Resident #325's care plan dated 09/27/21 revealed the following in part: Focus - Resident has a diagnosis of COPD Goal - Will be free of s/sx of respiratory infections through review date. Interventions - .Give oxygen therapy as ordered by the physician. Focus - Resident has heart disease. I am at risk for associated cardiac complications such as chest pain, SOB, . AFIB, CHF/heart failure . Goal - I will tolerate my medication and treatments regimen to manage my heart disease without any adverse affects or associated complications through my next due date. Interventions - .Oxygen as ordered/recommended by my Physician Observation on 10/5/2021 at 9:59 a.m., Resident #325 was lying on his side in his bed sleeping. Resident #325 responded to his name being called. The oxygen setting was on 4 liters, and the nasal cannula was not in his nostrils, it was slightly to the side of his nose. The oxygen was connected to an oxygen system directly in the wall. Resident #325 said he was not having any shortness of breath. Resident #325 said he had been on the oxygen since he was transferred to the facility. Record review on 10/05/2021 at 11:15 a.m. of Resident #325's physician order summary dated 10/5/2021 revealed the resident did not have an order for oxygen administration. Record review on 10/5/2021 at 12:22 p.m. of Resident #325's nurse's note (written by LVN L) dated (effective date 9/2/2021 and created date 9/3/2021) revealed the following in part: Resident arrived per ems/stretcher in stable condition .o2 per nc at 4L . Interview on 10/5/2021 at 12:24 p.m. with LVN M said she did not see the order for Resident #325's oxygen. LVN M said she though it was 4L but could not be sure since it was not in the system. LVN M asked the ADON to find the order and clarify what Resident #325's oxygen order was. Interview on 10/5/2021 at 12:27 p.m. with the ADON said she was not sure why there were no orders for oxygen administration for Resident #325. The ADON said it should have been updated after orders were received and if they had not been received, the orders should have been clarified with Resident #325's physician. The ADON said she was aware that Resident #325 was currently on oxygen and had been since he was admitted . The ADON said Resident #325's physician should have been called to verify the oxygen order. The ADON said she or the DON should have reviewed Resident #325's orders to ensure they were as ordered by the physician. The interview ended with the ADON going into an office on the phone with Resident #325's physician to clarify the oxygen order. The ADON said oxygen should not have been administered without an order. Interview on 10/05/2021 at 12:38 p.m. with the DON said all order should be verified with the physician to ensure Resident #325 and all residents orders are as ordered by a physician. The DON said after the orders are verified, then the orders would be put into the resident's electronic record. The DON said the facility does not have paper charts. The DON said she was not aware the oxygen order was missing for Resident #325. The DON said the resident must have arrived with the oxygen therefore that is why he currently was using it. Interview on 10/7/2021 at 9:34 a.m. LVN L said she was on duty when Resident #325 was admitted . LVN L said she checked to see if the medications that were on his discharge record from the hospital were present and they were. LVN L said Resident #325 had oxygen on when he arrived at the facility. LVN L said LVN C helped her and put in Resident #325's orders into the electronic record. LVN L said she did not call to clarify if Resident #325's oxygen order. LVN L said normally the ADON or DON will check the orders the following day. Interview on 10/7/2021 at 9:49 a.m. with LVN C said she put in the medication orders for Resident #325. LVNC said I was just trying to help out and only did medication strictly. LVN C said she did not have a reason why she did not include or clarity the oxygen order, she repeated I only helped out and we worked as a team. LVN C said oxygen is a treatment and was not listed on the discharge medication from the hospital. LVN C said she had not been provided specific training on how to update orders for a resident. LVN C later said there is an admission binder, but she did not follow it. LVN C said she did not feel it was her responsibility to verify the orders or use the binder because she was not the admitting nurse. Record review of the facility policy Professional Standard of Care (dated 2/2017) revealed the following in part: .The community must obtain the physician's .signature on the order and return it to the clinical record in a timely manner 1) A licensed nurse may accept a physician's .order for the administration of medication or treatments when that order originates with one of the licensed practitioners and is merely communicated to the RN or LVN though another person .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs to be administered are checked against the physician's orders for one of six Residents (#73) observed during medication pass, in that: -MA E attempted to administer Resident #73's Fluoxetine HCL Capsule 60 mg (depression medicine) outside of the physician's order and was stopped by surveyor. This failure could place residents at risk for adverse effects and decline in health due to medications not being administered as ordered. Findings included: Record review of Resident #73's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypertension (high blood pressure), hyperlipidemia (high levels of fats in the blood), dementia (memory loss), and major depressive disorder (affects how you feel, think and behave). Record review of Resident #73 's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental status (BIMS) score of 4 out of 15 indicating severe impairment. Further record review revealed Resident # 73 required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, transfers and required the use of a wheelchair for mobility. Resident #73 had impaired range of motion to the lower extremity on both sides. Further review revealed that Resident #73 was always incontinent of bowel and bladder. Record review of Resident #73's undated Care Plan read in part . Focus: The resident requires anti-depressant medication r/t the effects of Major Depression and Bipolar disorder AEB decrease in sleeping and periods of aggression . Goal: Resident will have no complications r/t anti-depression medication through review date. Interventions: Administer medication per MD orders . Record review of Resident #73's Physician orders revealed an order dated September 2021 for FLUoxetine hydrochloride (HCL) Capsule 40 milligrams (mg) give one tablet by mouth one time a day for depression. Start Date-04/07/2021 0700 (7:00am) Discontinue (D/C) Date-9/21/2021 1258 (12:58pm). Record review of Physician order revealed: FLUoxetine HCL Capsule 60 mg give one tablet by mouth in the morning for depression. Start Date-09/22/2021 0700 (7:00am) D/C Date-10/7/2021 0852 (8:52 am). Record review of the Information retrieved on 10/8/2021 https://www.drugs.com/fluoxetine.html indicated: Fluoxetine is a prescription medicine used to treat major depression, panic, anxiety or obsessive -compulsive symptoms. Take fluoxetine exactly as prescribed by your doctor. Follow all directions on your prescription label read all medication guides or instruction sheets. Your doctor may occasionally change your dose. Observation and interview on 10/7/21 at 7:52a.m, revealed MA E began to prepare Resident #73's morning medications which included the medication FLUoxetine HCL. After preparing Resident #73's medications on top of her medication cart and placing them in a small plastic cup, the surveyor asked MA E if she was ready to administer the medications and MA E said yes and proceeded to pick up the small plastic cup and go into Resident #73 's room with the morning medications that included the FLUoxetine HCL 40 mg which had been changed on 9/22/21 to FLUoxetine HCL 60 mg on the Physician's order. The surveyor stopped MA E and asked her to look at the orders before giving the medication FLUoxetine HCL 40 mg to Resident # 73. When MA E looked at the Physician's order, she said she did not see the new order because she was looking at what was listed on the blister pack. MA E said she was not going to give the medication FLUoxetine HCL 40mg now because she needed to notify the nurse regarding the Physicians order and said she only had FLUoxetine HCL 40 mg in her cart. MA E said she should have looked at the order and blister pack to compare and the risk of not checking the orders before giving medications was that a resident would not receive their ordered medications and it could cause them to have problems like being under medicated. Interview on 10/7/21 at 8:21 am, RN A said MA E had to always check the Physician's order before giving medications and said she was going to send a fax to the Pharmacy for the FLUoxetine HCL 60 mg to be filled. RN A said the risk of not giving medications as ordered was that the resident could have had increased problems with depression because of being under medicated when she did not receive the full dose of ordered medication. RN A said all staff who administer medications had to get end of shift reports, check medication labels and compare it with the Physician orders. RN A said she was not sure why the medication order for Resident # 73 was not changed but she was going to in-service all nurses again on medication administration. Interview on 10/7/21 at 10:02 a.m., the Director of Nurses (DON) said she was informed about MA E attempting to administer the FLUoxetine HCL 40mg for Resident #73. The DON said it was wrong to administer a medication without checking the Physician's order. The DON said all nurses will be in-serviced again on medication administration immediately. The DON said the facility had a policy on medication administration and the rights on medication administration and she would provide a copy to the surveyor. Record review of the facility's policy, Medication Administration dated April 2011 read in part: Objective: Resident medications are administered in an accurate, safe, timely, and sanitary manner. Fundamental Information: Physician's Orders- Medications are administered in accordance with written orders of the attending physician. 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physicians order shall be checked for the correct dosage schedule.

Based on interview and record review the facility failed to develop and implement written policies and procedures for 1 (Dietician) of 22 employees reviewed for Abuse, Neglect and Exploitation procedures. -The facility failed to complete an annual Employee Misconduct Registry/Nurse Aide Registry checks for the Dietician. -The facility failed to keep EMR/NAR records on file at the facility. This failure could place residents at risk of abuse, neglect, and exploitation. Findings included: Record review of facility policy Background Investigations (rev. August 2013) revealed the following in part: Background checks will be conducted prior to hiring applicants for employment, and types of background checks will also be conducted for vendors will also comply with state or federal requirements to complete certain checks on a periodic basis, such as monthly . 1. c. Background screen form which acknowledges we will conduct a screen with the Misconduct Registry as well as Criminal History. 2. Nurse Aide Registry and Employability Registry for all candidates regardless of role. Record review of facility policy Resident Abuse Policy (rev. July 2018) revealed the following in part: . K. Background Screening Investigation .will conduct employment background screening checks .and criminal conviction investigation checks on individuals making application for employment . 2. When conducting background investigations, our Community may consult any or all of the following agencies: a. Local, state, and/or federal law enforcement agency . 3. Prior to hire all applicants and team members will be checked as required by state regulation. Record review on 10/8/2021 of Employee files revealed the following: Dietician - DOH was 3/7/2019 - There was not an initial or annual EMR/NAR check in the personnel file. Interview on 10/08/2021 at 11:28 a.m. with HR said, I don't keep the employee information for the contracted workers because they don't work for us. HR said the dietician and contracted staff do work in direct contact with the residents of the facility. HR said, I don't know the status of the Dietician's EMR's check. HR said she is supposed to run the EMR's to see if the employees had an offense on their record that would prevent them from working in the facility. HR said the EMR's are ran to keep the residents safe from abuse. HR said she does not keep the records of contracted workers on site at the facility because the Dietician is contracted and doesn't work for the facility. She said the dietician reached out to the corporate office to see if the EMR's had been ran, but never heard back from them. HR said she was not aware if the Dietician had any offenses that would bar her from employment. Interview on 10/08/2021 at 11:59 a.m. with the Administrator said they did not have the personnel files for the contracted staff which included the Dietician, because it was maintained by the facility's corporate office. Interview on 10/08/2021 12:25 p.m. with the Administrator said they did not run the background checks on contracted staff because they did an initial Medicaid /Medicare provider eligibility search upon hire. The Medicaid/Medicare provider eligibility search if to ensure the provider can provide medical services to residents. The Administrator said the Dietician does visit with resident in their rooms and there is potential for abuse. The Administrator said she was not aware of the regulation that required the facility to make sure that the EMR/NAR was ran yearly after the initial at hire. Interview on 10/8/2021 at 12:28 p.m. with the HR said she is not responsible to have the EMR/NAR's completed and it was the responsibility of the contract agency. She said it was her understanding that she did not need to have the EMR/NAR check in the file and it was the responsibility of the contracted agency. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection to include handwashing and wound care for 1 of 6 residents (Residents #27) reviewed for infection control in that: -WCN did not change gloves when going from dirty to clean during Resident #27's wound care. This failure could place residents at risk of cross contamination and spread of infection. The findings included: Resident #27 Record review of Resident #27's admission face sheet revealed she was a 41 -year - old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: hyperlipidemia (high levels of fats in the blood), type 2 diabetes mellitus (high levels of blood sugar), paraplegia (loss of movement in both legs), pressure ulcer of sacral region (pressure injury to area of lower back near the spine). Record review of Resident #27's Physician orders dated September 2021 read in part . Cleanse coccyx (tailbone) with NS, pat dry, apply Alginate and cover with Foam Border and dry dressing every day shift every Mon, Wed, Fri for Wound Healing. Record review of clinical progress note revealed, Date 10/6/21 13:44 (1:44 pm) Type Skin/wound Note Text: Wound care rounds weekly, resident seen for sacrum (triangle shaped bone at the base of spine) wound stage 4 pressure, wound size, 1x0.9x0.9 cm (centimeter) undermining (surgical technique used to lift skin up and away from soft underlying tissue) noted 1 cm at 11 O'clock. Exudate (fluid produced during wound healing) moderate serous (yellowish color with small amounts of blood) draining, 20% slough (dead tissue), 50% granulation tissue (produced during the repair phase of healing) 80% peri wound maceration (skin broken down by moisture) at this time, Wound culture and X-ray of the sacrum at this time. Record review of Resident #27's undated Care Plan read in part . Focus: I have a stage IV pressure ulcer to my coccyx. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Focus: The resident is at risk for wounds due to Paraplegia, needing assistance with bed mobility, and evident by currently having wound. Goal: Resident will have intact skin, free of redness, blisters or discoloration with no new wounds by/through review date. Interventions: Apply treatments as ordered. Observation on 10/7/21 at 8:55 am, the WCN was observed standing at her wound care supply cart. She cleaned a white tray and placed clean wound care supplies on top of the tray then placed it on the bed side table of Resident # 27. WCN went back to her supply cart and retrieved a red plastic bag. WCN dropped the red plastic bag on the floor at the bedside, picked it up with gloves on and removed a roll of tape from the white tray with clean supplies. The WCN taped the red plastic bag to the bedside table she was using and placed the roll of tape she picked up back on the white tray with her clean wound care supplies without changing gloves or performing hand hygiene. Resident # 27 was observed lying on her side with a wound care dressing on her bottom. The WCN removed the soiled dressing, and performed hand hygiene before changing gloves, she picked up three separate wet gauze dressings, cleaned the wound and then picked up three separate clean dry gauzes from her white tray without performing hand hygiene or changing gloves before touching her clean wound care supplies and dried Resident #27's wound after she used the wet gauze. Interview on 10/7/21 at 9:18 am, WCN said she had worked at the facility for 3 or 4 months and said she received wound care in-service/training when she first started working. The WCN said she should not have picked up the red bag from the floor and should not have used the roll of tape before performing hand hygiene and should not have placed it back on the tray with her clean supplies. The WCN said she should have changed her gloves after cleaning Resident #27's wound and before picking up the clean dry gauze from the white tray with wound care supplies because the risk of not following procedure was spreading infection. The WCN said she didn't follow the correct wound care procedure because she was nervous and said that was not an excuse because of cross contamination. Interview on 10/7/21 at 2:33 pm the DON said the WCN should have followed the correct wound care procedure when she provided wound care to Resident #27. She said the WCN should not have picked up the red bag off the floor and then touched the roll of tape without performing hand hygiene. The DON said the WCN should not have placed the tape back on the tray with clean supplies after using it. The DON said the WCN should have changed her gloves and performed hand hygiene before touching any clean wound care supplies because of the risk of cross contamination. The DON said she was going to provide an in-service for wound care and infection control immediately. Record review of facility policy on Competency Assessment Dressings, Dry/Clean (Revised September 2013) read in part . A) Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. D) Clean bedside stand. Establish a clean field . 5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash hands and dry your hands thoroughly . 11. Using clean technique, open other products (i.e. prescribed dressing; dry clean gauze). 12. Wash and dry hands thoroughly. 13. Put on clean gloves . .