**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #1 received care in accordance with professional standards when the resident, who was diagnosed with type II diabetes, did not have any orders or monitoring tools to monitor for hyper/hypoglycemia when he re-admitted to the facility on [DATE]. This failure could place residents at risk of not receiving appropriate treatment, which could result in a decline in health and serious harm. Findings included: Record review of Resident #1's face sheet, dated 08/29/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included Metabolic Encephalopathy (brain does not function properly due to underlying metabolic disturbances), End Stage Renal Disease (kidneys have permanently lost most of their function and no longer adequately filter waste products and excess fluid from blood), Type 2 Diabetes Mellitus with Hyperglycemia (chronic condition characterized by blood sugar (hyperglycemia) due to the body's inability to use insulin effectively). Record review of Resident #1's care plan, dated 08/08/25, reflected Resident #1 was diagnosed with Diabetes Mellitus. The facility's interventions included: checking fasting serum blood sugar as ordered by doctor, monitoring, documenting, and reporting as needed any signs or symptoms of hyperglycemia or hypoglycemia, monitoring, documenting, and reporting as needed any signs and symptoms of infection to any open areas which included redness, pain, heat, swelling or pus formation., and a dietary consult for nutritional regimen and ongoing monitoring.Further review of this document reflected Resident #1 was not care-planned for a behavior of refusing care or treatment. Record review of Resident #1's order summary report, dated 08/11/25, reflected the following:Hyperglycemia and Hypoglycemia monitoring every shift for diabetic monitoring for diabetic monitoring. Start date 08/11/25; end date: 08/18/25. Record review of Resident #1's PPS MDS Assessment, dated 08/14/25, reflected BIMS was incomplete without any codes. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to substantial assistance with most ADLs. For mobility, Resident #1 required substantial assistance with most mobility activities and required a manual wheelchair. Record review of Resident #1's progress notes from MD on 08/23/25 at 09:13AM reflected the following: Chief complaint: Encounter for pain management. History of Present Illness (HPI): Visit for chronic pain management after recent re-admission to the facility. Recently hospitalized for a syncopal episode (sudden fainting) secondary to a drop in blood sugars and blood pressure. [Resident #1] Has no memory of the event or transport to the hospital. [Resident #1] Reports he was told he complained of difficulty breathing at the time. [Resident #1] denies any recent falls. [Resident #1] Reports current pain management regimen is effect, allowing participation in therapy services. Record review of Resident #1's hospital records, dated 08/26/25, reflected in part the following: admit date and Time: 8/26/2025/4:49 AMHistory of present illness: [Resident #1] is a 66 y.o. male and presents with new back pain after [Resident #1] fell out of his bed early this morning August 26, 2025 at his nursing home and also present with new confusion. Bedside nurse also reports recent administration of IV glucose as [Resident #1] is hypoglycemic (low blood sugar) with blood sugar in the 50s.POCT Glucose:-08/26/25 at 5:32 AM- 91 (reference range 70-110 mg/dL)-08/26/25 at 8:31 AM- 74 (reference range 70-110 mg/dL). An interview on 08/29/25 at 08:00AM was attempted with Resident #1's RP; however, she was unavailable to be interviewed. In an interview and observation at the local hospital on [DATE] at 08:25AM, Resident #1 stated he was at the hospital due to hurting his back from a fall. Resident #1 stated he fell out the bed on 08/26/25 at approximately 4:00AM when he attempted to turn over. Resident #1 could not recall if he felt weak or fatigued at the time of fall. Resident #1 stated he was diabetic, and the facility was aware. Resident #1 stated he told the facility that he needed a snack at 12:00AM and 4:00AM due to low blood sugar; however, he could not remember if he was receiving them. He also stated the facility did not check his blood sugars. Resident #1 was expressive and receptive to language; however, he seemed to have confusion regarding details of events. Resident #1 was lying in hospital bed with no visible marks, bruises or obvious injuries. In an interview on 08/29/25 at 12:32 PM, CNA A stated she was employed at the facility for 5 months. She stated she worked on the first floor East and West. She also stated she picked up additional shifts but mainly worked in the morning. She stated she worked the night shift on 08/25/25. CNA A stated she first worked with Resident #1 on the night on 08/25/25, and she was not aware that the resident was diabetic. CNA A stated she did not know that Resident #1 was supposed to get a snack at nighttime. She stated the nurses gave snacks to the diabetic residents. She stated there were snacks in a refrigerator available for all residents. CNA A stated she did not know Resident #1 if Resident #1 was getting his blood sugar checked because the nurses were responsible for doing it if needed. In an interview on 08/29/25 at 01:30PM, the MD stated he had been a doctor for over two decades. The MD stated Resident #1 was his patient at the local hospital as well as the facility. The MD also stated he was familiar with the case. The MD stated although resident was diagnosed with type II diabetes, he was not insulin-dependent; therefore, he did not need an order for any insulin or oral medication for diabetes. The MD stated he refused to order treatment or monitoring for Resident #1's diagnosis of type II diabetes. He stated Resident #1 had previously refused medication for his diabetes. The MD also stated resident was non-compliant with care and would not have allowed staff to check his blood sugar, so he was not going to order it. The MD also stated Resident #1's diabetes was diet-controlled; however, he was unable to say how Resident #1's diabetes was monitored without any MD orders in place. The MD stated resident received bloodwork when he was in the hospital and his A1C levels (test to measure average amount of sugar in blood) indicated he was no longer diabetic. The MD stated Resident #1 had problems of weakness which caused his falls due to renal failure and non-compliance with dialysis and had nothing to do with the MD or facility doing anything wrong. The MD stated even at home, Resident #1 was non-compliant with dialysis and did not his check blood sugar. The MD stated low blood sugar could possibly cause weakness. He stated some other symptoms included was sweating, shakiness and confusion. The MD contributed Resident #1's overall weakness and decline in health to end-stage renal failure and non-compliance with dialysis and care but was unable to state how diabetes was being ruled out since it was not being monitored. In an interview on 08/29/25 at 1:54 PM, the DON stated Resident #1 was a diagnosed with diabetes and he was also on dialysis. She stated Resident #1 was very non-compliant with his dialysis treatments. She stated Resident #1 was also a fall risk because he thought he could still do things independently and refused to call for help. The DON stated Resident #1 went to the hospital on [DATE] after the nurse found that he was not acting like himself and was less responsive, and he was currently at the hospital after having a fall on 08/26/25. The DON stated Resident #1 also had a fall the previous day on 08/25/25, and both falls occurred around 3:00 AM-4:00 AM. She stated Resident #1 had multiple comorbidities and the incidents could have been caused by many things including weakness related to low blood sugar, missing dialysis treatments, and even from receiving dialysis treatments. The DON could not recall the MD giving specific orders for Resident #1 to have overnight snack for his blood sugar; however, she stated snacks are always offered to residents at bedtime, especially residents with diabetes. In an interview on 08/29/25 at 02:57PM, RN B stated she worked at the facility for 8 years, 6:00AM-6:00PM shift. RN B stated she did not know Resident #1; however, she worked with other residents who were diagnosed with diabetes. She stated not all diabetics required insulin. She stated she checked blood sugar levels per the MD orders. RN B stated some residents had blood sugars checked often, and others were only checked as needed. RN B stated while on her shift, she would assess all residents with diabetes for symptoms of hyperglycemia/hypoglycemia. RN B stated symptoms of hypoglycemia was sweating, confusion, slurred speech, lethargic, shaking, and weakness. RN B also stated a resident with type II diabetes could have falls. She stated if any diabetic residents had symptoms, she checked their blood sugar even without doctor's orders based on her training as a nurse. In an interview on 08/29/25 at 04:24PM, LVN C stated she worked overnights with Resident #1 on 08/25/25. LVN C around 10:00PM, she gave Resident #1 3 cups of jello and a protein snack, and the resident finished all of it. She stated Resident #1 did not display any signs of hypoglycemia before going to bed. LVN C stated although she assessed Resident #1 for hypoglycemia, she did not document it anywhere. LVN C stated if a resident had a blood sugar monitoring tool ordered, it would show on the MAR for the nurses to sign off on; however, Resident #1 did not have one in place when she worked with him on 08/25/25-08/26/25. LVN C stated she found Resident #1 on the floor around 3:00 AM on 08/26/25, and the resident told her that he had fallen out of bed and was in pain. LVN C stated she completed an assessment and checked his vital signs, and Resident #1 did not have any symptoms of hypoglycemia.; however, he was sent to the hospital due to complaining of pain in his head and back. LVN C stated as a nurse she knew to check for symptoms of hypoglycemia during any assessment for residents who were diagnosed with diabetes, even if there was not an order in place to do so. LVN C was able to state symptoms of hypoglycemia included sweating, shaking, and confusion. Further interview on 08/29/25 at 06:32PM, the DON stated it was her responsibility to ensure that residents had appropriate orders in place, and if they did not she would have to discuss it with the MD. She stated the facility would put a monitoring tool in place to assess all residents with diabetes for hypoglycemia and hyperglycemia; however, Resident #1 went to the hospital on 8/20/25 and the system discontinued all his orders. She stated it was her responsibility to ensure that all of Resident #1's orders were made active as appropriate when he returned to the facility, but she was working the floor that day and forgot to check them. The DON stated if a resident was diagnosed with type II diabetes with no physician orders or hyperglycemia/hypoglycemia monitoring tool in place, it could place the resident at risk of being hyperglycemic/hypoglycemic. The DON stated not everyone had the same signs and symptoms of hypoglycemia; however, some of the signs and symptoms included confusion, sweating, shakiness, and unresponsiveness which could include weakness. In an interview on 09/02/25 at 05:13PM, Resident #1's RP stated Resident #1 was admitted to the facility on [DATE]. Resident #1's RP stated while at the facility, Resident #1 had an incident where his blood sugar was low, and he became extremely lethargic for two days and the facility allowed him to sleep. Resident #1's RP stated staff attempted to talk to Resident #1, but he did not respond. Resident #1's RP stated he went to the hospital (on 8/20/25) and found out his blood sugar was low. The RP stated the facility was not checking the resident's blood sugars. The RP also stated there was a second incident at the facility when Resident #1 had a fall, and she believed that was also due to low blood sugar. The RP stated Resident #1 was currently still at the hospital with a fractured back. Investigator requested the facility's policy on diabetic care from the DON and was informed the facility did not have one. The DON stated they followed guidelines from American Diabetes Association.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #29) of four resident's observed for infection control in that: LVN A failed to clean the scissors prior to or after usage during Resident #29's treatments. Placing the unclean scissors back on the treatment cart. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #29's 5-day MDS assessment, dated 05/26/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: diabetes, diabetic wound of the right heel, post-surgical wound of the right, and heart failure. Resident #29 BIMs score of 15 indicated the resident had intact cognition. Review of the Resident #29's plan of care dated 05/21/2025 with updates reflected goals and approaches to include wound care to a surgical wound right planter foot and a diabetic wound to the right heel. Review of the consolidated physician orders dated May 2025 reflected: order dated 05/23/2025 cleanse diabetic wound right foot apply alginate calcium with silver once daily, cover with abdominal pad for the next thirty days, and cleanse the post-surgical wound of right planter foot daily and apply an abdominal pad and wrap with gauze roll daily for the next thirty days. Observation on 06/10/2025 at 1:00 p.m. revealed LVN A went to the treatment cart and started preparing to perform wound care for Resident #29's diabetic wound on the right foot and the post-surgical wound of the right planter foot. LVN A did use hand gel and washed her hands prior to collecting supplies. The LVN took the calcium alginate/silver from the package, took scissors out of the drawer, without cleaning the scissors cutting off the top of the package. The LVN put the scissors with the supplies without cleaning them. LVN A gathered her supplies and entered Resident #29's room. LVN A washed her hands, put on her gloves, and gown used the scissors to remove the gauze on the post-surgical wound. LVN A cleaned the wounds with normal saline and then applied the silver nitrate to the wound on the diabetic wound. LVN A did not clean the scissors prior to using to cut the clean gauze placed on the post-surgical wound on the right planter foot. LVN A placed the scissors on the overbed table, removed her gloves, washed her hands, then took the scissors out of the room placing them on top of the treatment cart, and then placed the scissors back in the drawer of the treatment cart without cleaning them. In an interview on 06/10/2025 at 1:20 p.m., LVN A stated she was to prepare before completing the treatment with gathering her supplies, placing them on a clean area in the room, wash her hands, and placed on her gown and her gloves. LVN A stated she did not think of cleaning the scissors prior to using them because they were on the treatment cart and she thought the scissors were already cleaned, she said she did not clean them afterwards because she was nervous about completing the treatments correctly. She stated the risk would be spread of infection. In an interview on 06/12/2025 at 12:25 p.m., the DON (also infection control coordinator) stated the expectation was for the staff to clean all equipment used prior to using on residents and after using on residents. That included all direct care equipment, which included scissors. The DON stated she would have to complete more infection control in-serves for equipment cleaning in between residents, she had just completed an in-service on infection control recently with all direct care staff. The DON stated the risk in not cleaning the scissors would be cross contamination. If performing treatments, the nurse was to provide a clean surface to place wound care supplies on, and equipment should always be sanitized before and after usage. Review of the in-services given in the past three months reflected an in-service dated May 10th, 2025, for infection control and cleaning of equipment. LVN A had attended the meeting. Review of the facility's policy Infection Prevention and Control Program dated May 2023, reflected, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the . of soiled contaminated equipment .development and transmission of communicable diseases and infections . 10. Equipment protocol. a. all reusable items and equipment requiring special cleaning, disinfection . shall be cleaned in accordance with our current procedures governing the cleaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for one (Resident #282) of four residents reviewed for prevention and maintenance of pressure ulcers. The facility failed to ensure Resident #282, who was identified as entered the facility with a pressure sore to the sacrum and was at risk of developing additional pressure ulcers, received necessary treatment and services thru use of a low air mattresses, which was chosen as prophylaxis by the Wound Care physician to prevent the development of or worsening of pressure ulcers. This failure could place residents at risk of developing pressure ulcers or worsening of existing pressure ulcers. The findings included: Record review of Resident #282's 5-day MDS assessment dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] and discharged from the facility on 05/10/2024. Resident #282 had diagnoses which included: hypertension (high blood pressure), non-Alzheimer's dementia (confusion), and pressure areas (skin condition). Resident #282 was a BIMs score of 3 reflecting she was severely cognitively impaired, and unable to make decisions for herself and required one staff for assistance with activities of daily living. Further review of Resident #282's reflected she was incontinent of bowel and bladder, was dependent of for transfers, and bathing. Resident #282 had one unstageable pressure ulcer upon admission, receiving pressure ulcer care. Review of Resident #282's comprehensive plan of care dated 04/5/2024 with revisions dated 05/24/2024 reflected no noted goals or approaches for her behaviors related to her offloading her heels. Further review reflected, Problem: Resident #282 has pressure ulcers . left heel and right heel, that developed on 05/10/24, and unstable to sacrum (from admission) : goal: resident's pressure ulcer will show signs of healing and remain free of infection Intervention: Administer treatments as ordered . Focus: interventions: . pressure redistribution mattress as ordered by physician when in bed Further review reflected Problem: the resident is at risk for impaired skin integrity .goal the resident will understand the risks associated with my choice to not adhere to prevent skin breakdown and maintain skin integrity . Record review of Resident #282's May 2024 Physician Orders indicated . a group two pressure reduction mattress (low air loss rotating mattress) ordered 04/05/2024. Record review of Resident #282's May 2024 weight log indicated Resident #282 was 93 pounds. Record Review of Resident #282's Initial Wound Evaluations and Management Summary dated 05/10/2024 by Wound Care physician reflected two wounds: the left heel Length 3.0, Width 3.0 cm, Depth-not measurable and right heel Wound Size=Length 3.0, Width 1.0 cm., Depth- not measurable both with duration less than one day. The evaluation also reflected wound detail friction blister from rubbing heels on sheet. Record review of Resident #282's Skin-Acute Care Plan dated 04/05/2024 and revised 05/10/2024 documented Pressure Ulcer: unstageable lower sacrum .present on admission ., decreased mobility, incontinence, friction/shear . off-load wound, float heels and legs . group-2 Mattress (low air loss mattress) Approach: Pressure relief device: Air Mattress; Reposition every two hours; Treatment as ordered . In an interview on 06/10/2025 at 2:00 p.m. with Wound Care physician revealed she had provided care to Resident #282 during her stay at the facility. The Wound Care physician stated Resident #282 entered the facility with wounds on her sacrum and had developed pressure areas on her right and left heel while at the facility. The Wound Care physician stated she had met with the family and had instructed them on how a different type of mattress would be better than the mattress brought from the hospital, but the family felt the hospital's mattress was better. The Wound Care physician stated the resident was mobile in the bed and she would remove the pillows the staff was using to offload her feet and legs; the resident would throw them on the floor. The Wound Care physician stated this had opened the possibility for Resident #282 to develop wounds on her feet, since she would rub and lay her feet on the hard surface of the Group one mattress. Group two mattress would have allowed her feet to have alternating air pressure. The Group one mattress does not allow that. The Wound Care physician stated Resident #282 was here for a month, the mattress should have been changed during that time. The Wound Care physician stated, There would have been no guarantee the low air loss mattress would have helped, but how would we have known if we did not try. In an interview on 06/11/22024 at 02:33 p.m. RN E stated she was taking care of Resident #282 while she was here. RN E recalled going into Resident 282's room and she would be on a mattress overlay that was from the hospital. RN E stated not a mattress that the Wound Care physician would recommend, as it does not offer pressure protection. RN E stated the mattress is just a blow up that is placed over the mattress and then covered by a sheet. The Wound Care physician always recommends that the residents with high risk to develop skin issues should be on low air loss rotation mattress, allowing the body to have increased and decreased pressure at different time on each area of the body. RN E stated she did inquire as to why Resident #282 was not on a low-air loss mattress and was told the family had refused and wanted to use the mattress provided by the hospital. RN E stated that the resident was mobile in the bed and could remove the pillows that were placed under her heels and legs. The resident would remove the pillows and throw them on the floor consistently. RN E stated Resident #282 did develop wounds on the heels of her feet because she would remove the pillows and her feet would just sit on that hard blow-up mattress. Interview with the DON on 06/12/2025 at 2:00 p.m. revealed she was aware Resident #282 had a pressure ulcer upon admission and had developed pressure areas on each heel. Resident #282 used an air overlay mattress, from the hospital. The DON stated Resident #282's mattress had no adjustable air setting, it was just blown up and laid over the top of the mattress on the bed. The DON stated the purpose of the low air loss mattress was to prevent and treat pressure injuries, this is what the Wound Care physician had ordered, but the family did not want to use it. The staff tried to keep her feet offloaded with pillows, but the resident would remove them and throw them on the floor from the time that she admitted on [DATE] until she discharged on 05/10/24. Resident #282 never was on the ordered mattress (requested by the family) during her stay. The DON stated Resident did develop the pressure ulcers on both of her feet on 05/10/24. Review of the undated Medline Supra CXC Low Air Loss and Alternating Pressure Mattress Manufacturer Recommendations documented .Use for prevention and stage 1 through 4 pressure ulcers; pump alarms to indicate low pressure, Adjustable to patients' weight for customized therapy, 300 lb weight capacity .Directions for Use: .Pressure adjust knob controls the air pressure output. When turning clockwise the output pressure will increase. [NAME] versa for decreasing air pressure. Please consult your physician for a suitable setting . Record review of the facility policy titled Skin Management and Pressure Ulcer Prevention, dated 10/11/22, revealed the following [in part]: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, other altered skin integrity, and to provide treatment and services to heal pressure ulcer/injury and/or altered skin integrity, prevent infection and the development of additional pressure ulcers/injuries. It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and skin management. 1. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 2. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: i. Impaired/decreased mobility and decreased functional ability: ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus. iii. Drugs such as steroids that may affect healing. iv. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency. v. Resident refusal of some aspects of care and treatment. vi. Cognitive impairment. vii. Exposure of skin to urinary and fecal incontinence. viii. Under nutrition, malnutrition, and hydration deficits; and ix. The presence of a previously healed pressure injury. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessments of pressure injuries and altered skin integrity will be performed by a licensed nurse and documented on the Skin Observation Tool. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 4 residents (Resident #1) reviewed for parenteral fluids. The facility failed to manage Resident #1's PICC line dressing per professional standards and per the physician's order. This failure placed residents at risk of developing an infection. Findings included: Record review of Resident #1's admission MDS Assessment revealed the resident was a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Sepsis, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region; Pressure Ulcer of Sacral Region, Stage 4; and CKD. Resident #1 had a BIMS summary score of 15 which suggested intact cognition. The admission MDS Assessment revealed Resident #1 admitted with a Central IV Access. Record review of Resident #1's care plan, initiated 05/01/24, reflected interventions for the care of the PICC line site that included routine inspection and dressing changes as scheduled and as needed. Record review of Resident #1's active Physician Orders reflected: - Start Date 05/01/2024: Monitor PICC line site for redness, tenderness, edema, excessive bleeding at site, chest/neck/ear pain, numbness or tingling of affected arm/hand. Notify MD of abnormal findings every shift. - Start Date 05/05/2024: Dressing change to PICC site one time a day every Sun. - Start Date 05/05/2024: Change needleless connector to each lumen one time a day every Sun for PICC patency. Record review of Resident #1's May 2024 TAR reflected the following orders were signed off by the ADON on 05/12/24: - Change needleless connector to each lumen one time a day every Sun for PICC patency at 8:00 AM - Dressing change to PICC site one time a day every Sun at 8:00 AM - Measure the circumference of the PICC line mid-upper arm QD and PRN every day shift at 6:00 AM - Monitor PICC line site for redness, tenderness, edema, excessive bleeding at site, chest/neck/ear pain, numbness or tingling of affected arm/hand. Notify MD of abnormal findings every shift at 6:00 PM During an observation and interview on 05/13/24 at 10:57 AM, Resident #1 appeared clean, groomed, and dressed in a hospital gown. Resident #1 was observed in a semi-sitting position in bed. Resident #1 had a double lumen PICC line (two separate [purple; red] lumens [tubing] with ports) to the right upper arm covered by a transparent dressing dated 05/12/24 for IV antibiotics/fluids administration. The purple lumen did not have a needleless connector attached and the red lumen did not have a disinfectant cap placed over the end of the needleless connector to help prevent contamination. Resident #1 was Alert, attentive, and oriented to level of awareness of self, place, time, and situation. Resident #1 denied concerns about PICC line site or timeliness of care provided. During an observation and interview on 05/13/24 at 11:15 AM, LVN C said that each lumen had a needleless connector and disinfectant caps when she assessed Resident #1's PICC line site to the right upper arm. LVN C could not explain why the purple lumen was missing a needleless connector and the red lumen did not have a disinfectant cap. A sterile dressing change was observed to Resident #1's PICC line site at the right upper arm. There were no signs of redness, swelling, bleeding, or any other drainage around the catheter site was noted. One special disinfectant wipe was used to clean each lumen before placing a needleless connector to each lumen. Each port was flushed with 10 cc - 15 cc normal saline before a disinfectant cap was placed at the end of the connector. LVN C was observed appropriately connecting the scheduled IV antibiotic for administration. During an interview on 05/13/24 at 1:35 PM, the ADON indicated that she performed the task of changing Resident #1's PICC line dressing, applied new connectors to each lumen, and covered with disinfectant caps after each lumen was flushed on Sunday, 05/12/24. The ADON said that sterile dressings to PICC sites including the needleless connectors to the lumens should be changed every 7 days and PRN as reflected on the TAR. The ADON said that disinfectant caps should be placed over the end of the connector when the PICC line was not in use. During an interview on 05/13/24 at 1:42 PM, the DON indicated nurses were expected to change PICC/IV/CVC dressing changes every Sunday as scheduled/PRN and document. The DON stated the purpose of changing PICC/IV/CVC dressings every 7 days and as needed if appeared soiled or pulled away from the skin, place residents at risk of infection associated with IV therapy. The DON was unable to locate IV management policies. The DON stated steps of procedure for PICC/IV/CVC dressing change was reviewed with the nursing staff and ensured staff understood. The DON stated surveillance was conducted throughout the day to monitor maintenance of PICC/IV/CVC to avoid complications. During an interview on 05/13/24 at 2:00 PM, the NFA was not able to speak to the process of how central line dressings were changed and stated that the DON oversaw nursing clinical training and competency. The NFA could not produce related policies to IV Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #16) of 1 resident's reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #16 after thy returned from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #16's, admission MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included end stage renal failure (when kidneys suddenly become unable to filter waste products from blood), dependence on renal dialysis, (procedure to cleanse the blood), and Hypertension (increased blood pressure). Resident #16 had a BIMs score of 12, which reflected she was cognitively alert and oriented and able to make decisions for herself. The MDS section O related to special treatments, procedures, and programs reflected Resident #16 received dialysis. Record review of Resident #16's care plan, dated 04/26/2024, reflected Resident #16 received dialysis related to renal failure and was at risk for the potential complications related to dialysis. Needed hemodialysis to rule out end stage renal failure. Resident #16 will have no signs of complication from dialysis through next review. Obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and blood pressure to the physician. Record review of Resident #16's physician's order, dated 04/19/2024, reflected Hemodialysis every Monday, Wednesday, and Friday at 5:45 a.m. Further review reflected no orders to assess the access area prior to dialysis or post dialysis. Further review reflected orders to assess the access area prior to dialysis and after dialysis for the physician orders for the months of May 2024. Record review of Resident #16's EHR reflected inconsistent nursing documentation from 04/20/24 through 05/07/2024, regarding Resident #16's dialysis, monitoring of the resident's post-dialysis vital signs, or the assessment of the access area. Further review of the nurse's notes reflected on 04/24/24 it was documented by LVN E the resident returned from dialysis with vital signs checked and no assessment of the shunt; on 04/29/24 there was an assessment of shut after return; and on 05/01/2024 it was documented the resident returned from dialysis, but no assessment of the shunt. There were no assessments noted in the nursing progress notes about assessing the shunt from 04/20/24 through 05/07/24. Record review of Resident #16's dialysis communication forms reflected dialysis communication forms with no information on the resident's assessment and observation post-dialysis section on 04/22/2024, 04/24/2024,04/26/2024, 04/29/2024 (filled out but no assessment of the shunt), 05/01/2024, 05/03/2024, and 05/06/24 (filled out but no assessment of the shunt). Interview on 05/07/2024 at 10:30 a.m. with Resident #16 revealed when she returned from dialysis on the day shifts, the nurses did not assess her access area. Resident #16 stated she knew they were supposed to assess the access area, but they never did. The staff were sometimes busy with other responsibilities or their medication pass. Resident #16 stated she had asked, but the staff forget. She said she knew what to watch for herself, she really did not want to bother them . Interview on 05/08/2024 at 1:10 p.m. with LVN C revealed she was aware she was supposed to send Resident #16 and any dialysis residents with the dialysis communication form when she/they left for dialysis. The nurse on the next shift would collect the form when the resident returned from dialysis. LVN C stated she knew she was supposed to take the vital signs before she/they left and check to make sure the dressing on the access area was intact. LVN C stated if the access area was not assessed there could be a negative outcome, such as bleeding or infection, for the resident. LVN C stated the responsibility should be the charge nurse, but thought that the assessment should occur after dialysis, rather than before. Interview on 05/09/2024 at 11:31 a.m. with the DON revealed it was the nurses responsibility to send dialysis residents with a communication form to dialysis and get the form back when the resident returned to the facility. That was so, if there were orders from dialysis or changes, it was noted. She stated her expectation was for the nurses to perform post-dialysis assessments when the residents returned from dialysis and document on the dialysis communication forms on dialysis days. She stated failure to monitor the vital signs and access sight after dialysis, staff would not note the change of condition, bleeding, and whether the vitals were stable. The DON stated that if there were no orders given the nurses should call the physician and receive orders. It was basic nursing to know they must assess the access area before and after dialysis, as well as vital signs. She stated the risk for not assessing the vitals were that Resident #16 could be unstable and the shunt (special access used for dialysis treatment) could be bleeding. She stated the facility would do an in-service and monitor. Interview on 05/08/2024 at 2:40 p.m. with LVN D revealed when there was a resident that is going to dialysis, the nurse was to assesses the resident before they leave, to include wight, vital signs, and the access area (if it is a shunt the thrill and bruit, shunt (special access used for dialysis treatment), document on the communication form. When the resident returns form dialysis the nurse should reassess the resident, that would include vital signs, the dressing on the access area and the thrill and bruit. LVN D stated failure to monitor and assess resident's post dialysis put them at risk of low blood pressure and bleeding. In an interview on 04/30/24 at 2:30 p.m. revealed the DON there was no policy available for dialysis or dialysis documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two of three staff members (CNA A and CNA B) reviewed for infection control procedures. CNA A failed to perform hand hygiene after direct contact with residents while serving meals on the hallways, and CNA B failed to perform hand hygiene while delivering water to three residents. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #246's annual MDS assessment, dated 04/30/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #246 had diagnoses which included: septicemia (infection that has spread to the bloodstream), urinary tract infection (within the last 30 days), hypertension (increased blood pressure), diabetes (increased sugar levels), and tracheostomy (tube surgically placed in trachea to maintain airway). Resident #246 was cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #196's annual MDS assessment, dated 05/06/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #196 had diagnoses which included: left hip osteoarthritis (degenerative joint disease that causes joint damage), coronary heart disease (disease of heart's major blood vessels), peripheral vascular disease (poor circulation to limbs), pulmonary fibrosis (lung tissue is damaged and scarred), and a personal history of malignant neoplasm of breast (history of breast cancer). Resident #196 as cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #85's annual MDS assessment, dated 04/11/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included: Parkinson's disease (muscle and nerve disease), cellulitis of left finger (infection of left finger), hypertension (increased blood pressure), dysphagia (difficulty swallowing), and weakness. Resident #85 was cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #98's annual MDS assessment, dated 05/05/24 (not completed), revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The cognitive status in MDS had not been completed at the time of exit on 05/9/24. Record review of Resident #98's face sheet revealed diagnoses which included: enterocolitis due to clostridium difficile (bacterial infection of intestines), severe protein-calorie malnutrition (inadequate protein intake), acute systolic (congestive) heart failure (heart does not pump blood as well as it should), atrial fibrillation (irregular rhythm of the heart), and stage 4 pressure ulcer of sacral region (sore on area above the tailbone that extends to muscle, tendon, or bone). Resident #98 required assistance of staff for activities of daily living. Record review of Resident #248's annual MDS assessment, dated 05/03/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #248 had diagnoses which included: morbid (severe) obesity (overweight), anxiety (mood disorder), hypertension (increased blood pressure), hyperlipidemia (high levels of fat particles in the blood), and depression (mood disorder). Resident #248 as cognitively intact with a BIMS score of 15 and required assistance of one staff member for activities of daily living. Record review of Resident #97's annual MDS assessment, dated 05/08/24 (not completed), revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #97 had diagnoses which included: urinary tract infection, renal insufficiency (kidney function is decreased), hypertension (high blood pressure), cerebrovascular accident (stroke), hypertension (increased blood pressure), hyperlipidemia (high levels of fat particles in the blood), and diabetes (increased sugar levels). Resident #97 required assistance of one staff member for activities of daily living. The cognitive status in MDS had not been completed at the time of exit on 5/9/24. Observation on 05/07/24 at 12:18 PM, revealed CNA A was pushing the meal cart down the hallway. CNA A was observed to enter Resident #246, #248, and #97's rooms touching each door handle and set up the residents' lunch trays, adjusted the overbed tables, unwrapped the utensils, and removed the tops off of the drinks for each resident. CNA A did not complete hand hygiene before going to the next resident. CNA A then returned to Resident #246's room and removed a pair of gloves from the box in the room. He then sat the gloves down and did not use them, repositioned the bedside table, and adjusted the items on the tray. CNA A then used utensils on the tray to feed Resident #246. After feeding the resident, CNA A left the room without washing hands or using hand sanitizer. Hand sanitizer was located on walls in hallways between rooms. Observation on 05/09/24 at 10:44 AM, revealed CNA B pushed the water cooler down the hall without gloves to the front of Resident #196's door, did not perform hand hygiene, touched the door handle and went inside Resident #196's room. Then CNA B went inside Resident #85's room and verbally offered water. CNA B then left that room and went inside Resident #98's room. CNA B did not perform hand hygiene before going to each resident's room. CNA B then used the white scoop on the side of the cooler and filled two cups. She took both cups into Resident #85's room, gave one cup to Resident #85 and adjusted the bedside table with bare hands. CNA B then took the other cup to Resident #98's room, placed the cup of water on the bedside table, and touched the bedside table. CNA B touched the door handle and left the room. CNA B did not perform hand hygiene during the observation. Hand sanitizer was located on walls in hallways between rooms. An interview on 05/08/24 at 12:37 PM, CNA A stated they should always wash their hands when removing gloves or use hand sanitizer. CNA A also stated when passing trays sometimes they use hand sanitizer, but if they are using gloves, they don't have time to perform hand hygiene between residents. An interview on 05/09/24 at 1:07 PM, the DON stated when passing trays CNAs were expected to complete hand hygiene between each resident. The DON also stated CNAs were expected to complete hand hygiene between residents when administering water. Record review of the facility's policy Infection Prevention and Control Program dated 5/13/23 revealed: Standard Precautions a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for clinical records. The facility failed to ensure staff documented need for Resident #1 to receive oxygen treatment. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #1's undated electronic face sheet a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of hypokalemia (a lower-than-normal potassium level in your bloodstream), Hypernatremia (common electrolyte problem), hyperosmolality (loss of water also makes the blood more concentrated than normal), dementia without behavior disturbance, dysphagia (swallowing difficulties) Review of Resident #1's admission MDS Assessment, dated 10/18/23, reflected a BIMS score was not completed. The MDS did not indicate that oxygen was required for Resident #1. Review of the care plan completed 10/18/23 revealed the resident required assistance with act of daily living. The care plan did not indicate that oxygen was required for Resident #1 Review of Resident#1' nursing note dated 10/29/23 at 7:42PM authored by RN #1 revealed Resident #1's oxygen level was at 95% and resident on 3 liters of oxygen via nose cannula. There was no documentation of Resident#1's oxygen being low, nor the physician or family being notified of the resident receiving oxygen. Review of the electronic physician orders dated 11/07/23 revealed no order for oxygen. Review of the standing orders revealed oxygen per nose cannula to keep oxygen stats above 92 percent. Interview on 11/07/2023 at 1:45PM with RN #1 revealed he had worked in the facility for 4 years. He stated upon checking the oxygen levels for Resident #1 her oxygen was low. RN#1 stated he did not document the low oxygen level and only documented the oxygen level at 96%. RN #1 revealed there was a standing order which stated if the resident oxygen were below 92% then oxygen should have been given. RN#1 stated he was not sure how long Resident#1 was on oxygen due to his shift ending. RN#1 stated he did not notify the doctor nor family regarding oxygen being given. RN#1 stated he forgot to document the low oxygen level. Review of Resident #1's nursing notes dated 10/30/23 at 7:19 AM author by RN#2 revealed Resident #2 was met with oxygen at 3 liters via nose cannula. RN#2 noted Resident #1's oxygen saturation dipping when not on oxygen. RN#2 recorded Resident#1's oxygen status at 78%. RN #2 did not document that the physician was notified, nor an order given to continue oxygen . Review of Resident #1's nursing notes dated 10/30/23 at 3:43PM authored by the infectious disease doctor, revealed hypoxia on room air and Resident #1 on 2 liters of oxygen via nose cannula. There was no documentation of an order give for continued use of oxygen. Interview on 11/07/23 at 2:15PM with RN#2 revealed during rounds she noted that Resident#1 was receiving 3 liters of oxygen. She stated she attempted to remove the oxygen and Resident#1's oxygen saturation dropped to 78%. RN #2 stated she provided 3 liters of oxygen via nose cannula. RN#2 stated she contacted the physician and as given a verbal order to continue oxygen and a x ray was order. RN#2 stated she thought she documented the contact that was made with the physician. Interview on 11/07/23 at 3:00PM with the DON revealed there was a standing order for oxygen levels below 92%. The DON she did not think there was a need to get an order to continue oxygen due to the standing order being in place. The DON stated she did not think there was a risk to residents due not obtaining the order or contacting the physician due to the current standing order. Review of the facility policy Documentation of medical record dated 06/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation.

**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 prevent the development and transmission of infection for two of six residents (Resident #35 and #210) observed for infection control. CNA A failed to perform hand hygiene during while providing incontinence care to Resident # 35. CNA B failed to perform hand hygiene during while providing incontinence care to Resident # 210. This failure could placed the residents at risk for infection. Findings include: Record review of Resident #35's face sheet dated 3/15/23 reflected he was [AGE] years old male. He was admitted to the facility on [DATE]. He was admitted with fracture of tibia (larger of the two bones in the lower leg), respiratory failure, heart failure, difficult walking and need for assistance with personal care. Review of Resident #35's care plan initiated 2/13/23 reflected the resident had an ADL self-care performance deficit related to Orthopedic surgery and the intervention was for the resident to be assisted by staff for toileting. Observation on 03/13/23 at 10:40 AM revealed CNA A providing incontinent care for Resident #35. CNA A was in Resident #45's room when she left and stated she was going to get wipes. When CNA A came back in the room, she gloved without performing hand hygiene and proceeded to providing the resident with care. CNA A cleaned the resident and removed the dirty brief, the resident was soiled in urine. CNA A then placed the dirty brief in the trash can and cleaned the resident's bottom. After cleaning the resident without any form of hand hygiene or change of gloves, CNA A applied the clean brief, fastened the brief, and assisted the resident to position in bed. After care, CNA A completed hand hygiene. In an interview on 03/13/23 1at 2:02 PM with CNA A regarding the Resident #35's care, CNA A stated she was supposed to complete hand hygiene before and after care. Asked about in between care, CNA A stated after cleaning the resident she was supposed to clean her hands and change gloves before applying the clean brief. CNA A stated she was supposed to complete hand hygiene to prevent the spread of infection. CNA A stated she had completed a hand hygiene and infection control in-service about two months ago. Record review of Resident #210's face sheet dated 3/15/23 reflected she was [AGE] year old female. She was admitted to the facility on [DATE]. She was admitted with acute kidney failure, type 2 diabetes, altered mental status, hypertension, gout, and acute respiratory failure. Review of Resident #210's care plan initiated 03/07/23 reflected the resident had an ADL self-care performance deficit and the intervention was for the resident to be assisted by staff for toileting. Observation on 03/15/23 at 10:29AM reflected CNA B providing incontinent care to Resident #210. CNA B was observed entering Resident #210's room gloved without any form of hand hygiene and explained to the resident that she was to provide incontinent care. CNA B positioned the resident and unfastened her brief, then proceeded to cleaning the resident. When CNA B had completed cleaning, she took off the dirty brief and placed it on the edge of the bed. Without any form of hand hygiene or change of gloves, CNA B proceeded to apply the clean brief. After CNA B applied the clean brief, she picked up the dirty brief that was at the edge of the bed, and placed it in the trash can. With the same dirty gloves, CNA B covered the resident, positioned the resident, and moved the bedside table closer to the resident. After care, CNA B completed hand hygiene In an interview on 03/15/23 at 12:11 PM with CNA B she stated she was to complete hand hygiene before and after care and after taking off Resident #210's dirty brief. CNA B stated she was supposed to clean her hands when she initially started to provide care, and after she cleaned the resident before applying the clean brief. CNA B also stated she was supposed to take off the dirty gloves before touching the resident's bedding and bed side table. CNA B stated she was to complete hand hygiene for infection control, and she stated she was in-serviced on infection control about a month ago. In an interview on 03/15/23 at 1:05 PM with the DON, she stated infection control was important during care. The DON stated during care the staff were to use the hand sanitizer or wash hands if they were physically soiled. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean. The DON stated hand hygiene was to be completed for infection control. DON said she was the infection preventionist and in-service on infection control completed within a month ago. Record review reflected the facility completed an in-service on 02/27/23 for hand hygiene. Review of the facility policy dated 10/24/22 and titled Hand Hygiene reflected, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 12 residents reviewed for medication storage. The facility failed to ensure medication and medication supplies were secured or attended by authorized staff. This failure could result in resident access, overdose, ingestion of medications leading to a risk for harm, and possible drug diversion. Findings included: Resident #2 Record review of Resident #2's MDS assessment, undated, reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus without complications, unspecified Dementia, psychotic disturbance, mood disturbance and anxiety. BIMS not assessed. Record review of Resident #2 care plan initiated on 12/09/22 revealed Administer .medications as ordered by physician. Monitor for side effects and effectiveness every shift In an observation and interview on 12/22/22 at 9:55 AM revealed Resident #2 had a syringe left on top of her dresser. Resident #2 stated she did not know if the syringe was left from last night or from this morning. Resident #2 stated her nurse gives her insulin twice a day. In an observation and interview on 12/22/22 at 10:00 AM LVN A revealed syringes should be disposed of in the sharps container in the bathroom after used. LVN A stated Resident #2 was not at risk because she was aware. Resident #1 Record review of Resident #1's MDS assessment, undated, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute kidney failure, type 2 Diabetes, and congestive heart disease. BIMS not assessed. Record review of Resident #1 care plan initiated on 12/17/22 revealed Administer .medications as ordered by physician. Monitor for side effects and effectiveness every shift In an observation and interview on 12/22/22 at 11:48 AM revealed Resident #1 had two Nicotine lozenges containers (can help you quit smoking by replacing the nicotine in cigarettes) and a jar of icy hot (used for temporary relief of minor aches and pains) on her bedside table . There was a Levemir pen (used to control high blood sugar in people with diabetes) on top of the dresser. Resident #1 stated she took the Nicotine Lozenges whenever she needs one. Resident #1 stated the staff administered her insulin when she needed it. In an interview on 12/22/22 at 11:55 AM with LVN B, she stated residents should not have medications and their room. LVN B stated residents have to have physician orders for over the container medications and prescriptions. LVN B stated Resident #1 was in danger of overdosing. Resident #3 Record review of Resident #3's MDS assessment, undated reflected Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Sepsis, lack of coordination, low back pain, and need for assistance with personal care. BIMS moderately impaired. In an observation and interview on 12/22/22 at 12:15 PM revealed Resident #3 had Nystatin 100, 000 USP (Nystatin is used to treat fungal skin infections) and 2 roll on Biofreeze ((used to relieve itching and pain from certain skin conditions) on bedside table. Resident #3 stated she mixed the powder with Aquaphor and used it throughout the day for a sore on her buttocks area. Resident #3 stated she got the Biofreeze from physical therapy. Resident #4 Record review of Resident #4's MDS assessment, undated reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of congestive heart failure, acute respiratory failure and presence of cardiac pacemaker. BIMS not assessed. Record review of Resident #4 Care plan imitated 12/07/22 revealed, Administer .medication as ordered by physician. Monitor for side effects and effectiveness every shift. In an interview and observation 12/22/22 at 12:25PM revealed Resident #4 had Preservision 2 solution (eye supplement that might help improve the strength of the eye) and Areds 2 chewables (eye vitamins) on her bedside table. Resident #4 did not know what the chewable were for. In an interview on 12/22/22 at 12:40 PM with DON revealed some residents can self-administer medication. Record review of Resident #1 assessments revealed no self-administer medication assessment was documented. Record review of Resident #2 assessments revealed no self-administer medication assessment was documented. Record review of Resident #3 assessments revealed no self-administer medication assessment was documented. Record review of Resident #4 assessments revealed no self-administer medication assessment was documented. In an interview on 12/22/22 at 12:55 PM with the Administrator revealed there were no residents who self-administer their own medication. The Administrator stated that during morning rounds nursing staff should check rooms for visible medication and medication supplies that need to be locked and secured . Record review of facility's policy revealed Medication policies, 1. A written order for bedside storage of medication is present in the resident's medication records.

Based on observations, record reviews, interviews, and facility policy review, the facility failed to promote and facilitate resident self-determination through support of resident choice for one (Resident #107) of one resident reviewed for choices. Specifically, the facility failed to ensure Resident #107 was transferred in and out of bed at times desired by the resident. This had the potential to affect any resident requiring assistance with a mechanical lift for transfers. Findings included: A review of the facility's policy and procedure, titled Residents' Rights, last updated 06/01/2020, indicated Resident's rights included managing personal and financial affairs and make choices and independent decisions. A review of the face sheet indicated the facility admitted Resident #107 with diagnoses which included aftercare following joint replacement surgery with the presence of a right artificial knee joint and osteoarthritis. A review of the admission Minimum Data Set (MDS) assessment, dated 11/20/2021, indicated the resident had no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. A further review of the MDS indicated the resident required extensive assistance of one to two people for activities of daily living (ADLs) including bed mobility, transfers, dressing, toileting, and bathing. The resident was continent of bowel and bladder. A review of the comprehensive care plan, dated 11/22/2021, did not include the residents transfer status or the need for two persons assist with a Hoyer lift. The care plan did not include the resident's preference to be out of bed before 9:00 AM or to be back to bed before 7:00 PM. During an interview with Resident #107 on 11/30/2021 at 12:29 PM the resident stated they required a total body mechanical lift (Hoyer) to be transferred out of bed into the wheelchair and back. The resident stated it required two people to transfer with the Hoyer but some of the staff were able to do it by themselves otherwise the resident would have to wait long periods of time to get out of bed in the morning or back to bed at night. The resident stated they would prefer to be out of bed before 9:00 AM because they were tired of being in bed so long and back in bed between 6:00 PM and 7:00 PM because they were tired from being up in the wheelchair all day. Observation and interview on 12/01/2021 at 8:16 AM revealed Resident #107 was lying in bed in their room. The resident stated they had finished breakfast and was waiting to get out of bed. Observation and interview on 12/01/2021 at 9:50 AM revealed Resident #107 was lying in bed. Resident #107 stated they were getting anxious about getting up. During an interview with Certified Nurse Aide (CNA) P on 12/01/2021 at 9:50 AM, CNA P stated she was the only CNA on the floor for 16 residents. She stated if she needed help with a resident, she would ask the nurse. She stated if the nurse was busy sometimes the resident would have to wait. CNA P stated Resident #107 was a Hoyer lift and required two people so the resident had to wait until after breakfast before she could transfer them. CNA P stated the Hoyer lift they had for the 3rd floor was not working so she would have to go get one from a different floor. CNA P returned to the resident's room at 10:15 AM and with the assistance of another staff member (not the nurse on the floor), Resident #107 was transferred from the bed to their wheelchair. Observations on 12/01/2021 between 6:55 PM and 7:33 PM revealed the following: • At 6:55 PM, the door to Resident #107's room was closed. Two barrels (dirty linen and trash) were outside the door in the hallway. • At 7:33 PM, CNA R came out of Resident #107's room pushing the Hoyer lift. No other staff were in the room. CNA R stated the nurse assisted him to transfer the resident with the lift and then left the room. CNA R stated sometimes a resident that required two people assistance had to wait until they could get assistance but stated they were able to get all their work done. Continuous observations on 12/02/2021 between 7:59 AM and 10:21 AM revealed the following: • At 7:59 AM, Resident #107's door was closed. • At 8:02 AM, the call light in Resident #107's room went on and CNA P entered the room. The call light went off at 8:03 AM. • At 8:09 AM, CNA P and an occupational therapist (OT) came out of the room. Resident #107 was dressed but still lying on the bed. • At 8:20 AM, Resident #107 stated they wanted to get out of bed but was waiting for the CNA to get the lift. • At 10:10 AM, a staff member from central supply (who was also a CNA) brought a lift sling up to the 3rd floor and CNA P brought the Hoyer lift from another floor. They entered Resident #107's room and transferred the resident from the bed to the wheelchair. A review of the task report for transferring, completed by the CNAs, from 11/14/2021 through 12/02/2021, indicated the task was completed nine out of 19 days. A review of the task report for support required during transfers, from 11/14/2021 through 12/02/2021, the task was documented as being done three times with only one person assist. During an interview with Licensed Vocational Nurse (LVN) DD on 12/05/2021 at 1:14 PM, LVN DD stated every effort should be made to assist residents with their ADLs in a timely manner. She stated a resident that required a Hoyer lift would require two people to do the transfer, but the resident should not have to wait an extended period for the task to happen. She stated as the nurse on the floor, she was always willing to assist the CNA with resident care. LVN DD stated sometimes the resident would have to wait until she finished the task, she was doing but stated it was never longer than 15 minutes. During an interview with the Director of Nursing (DON) on 12/05/2021 at 1:36 PM, the DON stated a resident that required a Hoyer lift to be transferred would need two people to accomplish the task. She stated the CNA would get the nurse on the floor to assist, get a nurse manager or, if needed, go to another floor, and get a staff member from that floor to assist. During an interview with the Administrator on 12/07/2021 at 8:13 AM, the Administrator stated safety came first and that may mean the resident would have to wait to be transferred until two people were available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide proper notification of changes for one (Resident #91) of three residents reviewed for notification. Specifically, the facility failed to notify Resident #91's family of a change in status, failed to notify Resident #91's family of the resident being transferred out of the facility, and failed to notify Resident #91's family and the receiving facility of test results. This had the potential to affect any resident's that had a change of condition. Findings included: A review of the face sheet indicated the facility admitted Resident #91 with diagnoses which included dementia without behaviors, Parkinson's disease, and a traumatic subdural hemorrhage (brain bleed). A review of Resident #91's admission Minimum Data Set (MDS) assessment, dated 09/16/2021, indicated the resident had severely impaired cognitive function with a Brief Interview for Mental Status (BIMS) score of six out of 15. The resident required extensive assistance of one person for activities of daily living (ADLs) including bed mobility, transfer, dressing, toilet use and bathing. During an interview with Resident #91's family member on 12/01/2021 at 5:31 PM, the family member stated they were the Power of Attorney (POA) for the resident. The family member stated the resident was at the facility for rehab and was doing well and the plan was for the resident to be discharged home on [DATE] but when the family member arrived at the facility to pick up the resident, they were no longer at the facility. The family member stated they were told the resident was transferred to another facility several days earlier because the resident tested positive for COVID-19. The family member stated they were never informed that the resident tested positive for COVID-19 and were never told the resident was sent to another facility. The family member stated the facility said it was a lack of communication on their part. A review of a progress notes by the Nurse Practitioner (NP), dated 09/20/2021, indicated the resident was doing well with no concerns from the resident or therapy. The note indicated the social worker was following along for discharge needs and the discharge date was set for 09/24/2021. This was a late entry note that indicated it was created on 10/08/2021, 18 days after the resident was discharged from the facility. A review of another progress notes by the NP, dated 09/20/2021, indicated the NP was notified that evening that the resident had tested positive for COVID-19 and was being transferred to another facility. The note indicated the resident was asymptomatic upon exam earlier in the day and was stable for transfer to another facility at that time. This was a late entry note that indicated it was created on 10/08/2021, 18 days after the resident was discharged from the facility. The facility provided a xerox copy of two BinaxNOW COVID-19 Ag test cards. One card, labeled 1, had the residents name and room number on the card but was not dated. The second card, labeled 2, had the residents room number on the card but no name or date. Both cards displayed positive results. A review of a laboratory report indicated Resident #91 was tested for COVID-19 PCR (polymerase chain reaction) on 09/20/2021 and the final results, approved on 09/22/2021, indicated the resident was negative for COVID-19. A review of the resident's electronic health record (EHR) for September 2021 revealed there was no documentation the resident's family had been notified of the positive COVID-19 test or of the resident being transferred to another facility. There was no documentation to indicate the resident, the resident's family or the receiving facility were notified of the negative COVID-19 results obtained from the lab with a PCR test after the resident was discharged . During an interview with the Director of Nursing (DON) on 12/04/2021 at 10:22 AM, the DON stated the facility worked as a team to determine what the best approach was when a resident tested positive for COVID-19, and they had determined it was the best thing for Resident #91 to be transferred to a COVID-19 positive facility. The DON stated the admissions director called facilities to see who could accept the resident at that time. She stated they would send the resident's information to the facilities so they could review it and decide if they would accept them. The DON stated once they were accepted, a nurse from their facility would call the receiving facility and give them report. The DON stated she also communicated with the receiving facility. She stated it should be documented in the progress notes. She stated when Resident #91's negative COVID-19 test results came back from the lab, she notified the physician, but they had already sent the resident out. The DON stated she was unsure if there was any communication to the receiving facility about the negative test results. During an interview with Licensed Vocational Nurse (LVN) EE on 12/04/2021 at 11:12 AM, LVN EE stated she called the resident's family and told them the resident had COVID-19 and was being transferred to a different facility. LVN EE stated a family member would normally come in the facility everyday around 5:00 PM, so she was waiting for them to come in to tell them, but they did not show up, so she called them instead. LVN EE stated it should have been documented in a progress note but she could not remember if she documented it or not. She stated the resident was transferred out of the facility after her shift and she did not know which facility the resident went to. During an interview with the Administrator on 12/07/2021 at 8:13 AM, the Administrator stated Resident #91's family was notified by LVN EE when they tested positive for COVID-19 and said there were text messages between the LVN and the DON to prove the family was notified. The facility provided a piece of paper with the title text_0 at the top of it that the DON and LVN EE stated was the text communication between them when Resident #91 was being transferred with a request by the DON to LVN EE that the family be notified of the positive COVID-19 test and of the resident being transferred. The paper did not indicate the family had been notified. A policy and procedure on Notification was requested from the DON on 12/03/2021 and was not provided before the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, it was determined the facility failed to ensure allegations of abuse were reported immediately, but not later than two hours after the allegation was made for one (Resident #96) of seven residents investigated for abuse/neglect. This had the potential to affect 64 residents. Findings included: A review of the Abuse, Neglect, and Exploitation policy, revised 12/2017, revealed Verbal/written notices to agencies will be made within two (2) hours of the occurrence. A review of Resident #96's face sheet revealed the facility admitted the resident with the diagnoses that included bipolar, spinal stenosis, diabetes, sleep apnea, and muscle weakness. The resident was discharged from the facility on 10/22/2021. A review of Resident #96's five-day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS revealed the resident did not exhibit any behaviors. In an interview on 11/30/2021 at 8:12 AM, Resident #96 revealed an incident happened on Sunday night, 10/17/2021. The resident stated administrative staff was notified of the incident, but Registered Nurse (RN) S showed back up that Wednesday, 10/20/2021. A review of the incident report, dated 10/22/2021, revealed Patient was not clear on what night it was but [the resident] stated [the resident] asked the nurse [RN S] to give [the resident] the reacher (a stick with a claw at one end to aid in picking up things) and he said, 'I want to grab you' [the resident] said 'you better not' and he said, 'don't you want to grab me?' [The resident] said no and he left. The investigation findings were inconclusive. The date the incident was reported to the state agency was 10/22/2021. In an interview on 12/01/2021 at 7:06 PM, RN S stated he had not been suspended and was not aware of any allegation of abuse against him. An interview with RN S again on 12/01/2021 at 8:06 PM revealed he remembered the Director of Nursing (DON) had talked to him about the incident . RN S stated he thought he was off for three days but did not remember much. In an interview on 12/02/2021 at 9:38 AM, the DON stated she received a phone call Wednesday night (10/20/2021) about the incident. The DON stated the resident and Assistant Director of Nursing (ADON) B called her that night to talk about an incident that happened over the weekend. The DON stated they removed RN S from the resident's care that evening, but he was not suspended. An interview with the DON and ADON B on 12/02/2021 at 10:04 AM revealed that the resident had reported the incident to ADON B on the evening of 10/20/2021. ADON B stated the resident told him the incident had been reported previously and wanted to know why RN S was still providing care. They removed RN S from the care of the resident that Wednesday night, 10/20/2021. They said the investigation was started the next morning, 10/21/2021. They stated they were aware of the process of reporting and suspension pending investigation . In an interview on 12/03/2021 at 8:10 AM, the Administrator revealed the date the incident was called into the state agency was 10/22/2021 at 2:00 PM. In an interview with the Administrator on 12/03/2021 at 11:45 AM, the Administrator stated she talked to the resident in the morning on 10/22/2021 at 9:30 AM, and the resident reported the incident to her. The Administrator stated she did not find out about the allegation of abuse until 10/22/2021. The Administrator stated if the staff did not feel like it was an allegation of abuse, they may not have notified her. The Administrator stated they should have called her immediately to report the allegation of abuse. The Administrator acknowledged there was a failure, and the staff needed to be educated. The Administrator acknowledged the allegation of abuse should have been reported on 10/20/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to ensure the alleged perpetrator did not have access to the alleged victim and other potential victims during the investigation for one (Resident #96) of seven residents investigated for abuse/neglect. This deficient practice had the potential to allow alleged abuse to continue and instill fear in victim, leading to psychosocial or physical harm. This had the potential to affect 64 residents. Findings included: A review of the Abuse, Neglect, and Exploitation policy, revised 12/2017, revealed, Our facility will protect residents from harm during investigations of alleged abuse .Employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator. A review of Resident #96's face sheet revealed the facility admitted the resident with diagnoses that included bipolar, spinal stenosis, diabetes, sleep apnea, and muscle weakness The resident was discharged from the facility on 10/22/2021. A review of Resident #96's five-day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS revealed the resident did not exhibit any behaviors. An interview with Resident #96, on 11/30/2021 at 8:12 AM, revealed an incident happened on Sunday night, 10/17/2021. The resident stated administrative staff was notified of the incident, but the Registered Nurse (RN) S showed back up that Wednesday, 10/20/2021. The resident stated they were mad at first but then had panic attacks when they noticed RN S was still in the facility. The resident stated RN S was not suspended pending investigation. A review of the incident report, dated 10/22/2021, revealed, Patient was not clear on what night it was but [the resident] stated [the resident] asked the nurse [RN S] to give [the resident] the reacher (a stick with a claw at one end to aid in picking up things) and he said, 'I want to grab you' [the resident] said 'you better not' and he said, 'don't you want to grab me.' [The resident] said no and he left. The investigation findings were inconclusive. The date the incident was reported to the state agency was 10/22/2021. In an interview on 12/01/2021 at 7:06 PM, RN S revealed he had not been suspended and was not aware of any allegation of abuse against him. RN S stated he did not remember this resident or any allegations of abuse. RN S stated he had some training last month but could not remember what the training was. RN S stated he thought he had received training on abuse but could not remember. RN S confirmed he had not been suspended pending any investigations. In an interview on 12/01/2021 at 7:11 PM, Assistant Director of Nursing (ADON) A revealed there were four ADONs in the facility. ADON A stated she had heard of an allegation of abuse last month. ADON A stated she was not sure of the details. ADON A stated the resident had moved to a different floor. ADON A stated she was not aware if the staff member had been suspended. ADON A stated she was not sure if the staff member had been interviewed regarding the incident. ADON A stated she did not help with the investigation. In an interview on 12/01/2021 at 7:18 PM, ADON B revealed no allegations of abuse had been reported to him. ADON B stated he had heard about the incident with RN S secondhand. ADON B stated he had never talked to RN S about the incident. An interview with RN S again on 12/01/2021 at 8:06 PM revealed he remembered the Director of Nursing (DON) had talked to him about the incident. RN S said he thought he was off for three days but did not remember much. At this time, he stated the resident accused him of to grab. RN S stated he told the DON that he had not done anything. He stated he needed a certified nurse aide (CNA) to witness him giving pain meds to the resident, but that was what he remembered. In an interview on 12/02/2021 at 9:03 AM, ADON C revealed the resident reported an allegation about RN S. ADON C stated the resident said something fell and asked RN S to get the resident's grabber. She stated RN S grabbed it and said, Do you want to grab me. She said the resident said no and got upset. She stated the resident asked for RN S not to do direct care anymore. ADON C stated she was not sure if RN S was suspended after the incident. ADON C stated she did not remember the date. In an interview on 12/02/2021 at 9:38 AM, the DON revealed she received a phone call Wednesday night (10/20/2021) about the incident. The DON stated the resident and ADON B called her that night to talk about an incident that happened over the weekend. The DON stated they removed RN S from the resident's care that evening, but he was not suspended. The DON stated the resident was admitted on Friday, 10/15/2021. The DON stated the incident was reported to her 10/20/2021 and RN S was on the schedule Friday (10/15/2021), Saturday (10/16/2021), and Sunday (10/17/2021). The DON stated RN S was not in the facility Monday, 10/18/2021, or Tuesday, 10/19/2021. The DON stated when the resident saw RN S again, that may be what triggered the resident to report the incident on 10/20/2021. An interview with the DON and ADON B on 12/02/2021 at 10:04 AM revealed that the resident had reported the incident to ADON B on the evening of 10/20/2021.The ADON B stated the resident told him the incident had been reported previously and wanted to know why RN S was still providing care. They removed RN S from the care of the resident that Wednesday night, 10/20/2021. They stated the investigation was started the next morning, 10/21/2021. They stated they were aware of the process of reporting and suspension pending investigation. An interview with the Administrator on 12/03/2021 at 8:10 AM revealed the date the incident was called into the state agency was 10/22/2021 at 2:00 PM. In an interview on 12/03/2021 at 9:39 AM, Social Worker (SW) O stated she was not aware of any allegation of abuse from this resident. She stated they only contributed to helping with the investigation if the Administrator requests. In an interview on 12/03/2021 at 11:35 AM, SW V stated the social workers were involved in helping to investigate allegations of abuse in the past, but not currently. She stated social workers were not involved with abuse investigations. In an interview on 12/03/2021 at 11:45 AM, the Administrator stated she talked to the resident in the morning on 10/22/2021 at 9:30 AM, and the resident reported the incident to her. The Administrator stated she did not find out about the allegation of abuse until 10/22/2021. The Administrator stated if the staff did not feel like it was an allegation of abuse, they may not have notified her. She said they should have called her immediately to report the allegation of abuse. She acknowledged there was a failure, and the staff needed to be educated. The Administrator acknowledged the allegation of abuse should have been reported on 10/20/2021. The Administrator acknowledged RN S should have been suspended pending investigation on 10/20/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy reviews, the facility failed to ensure and provide safe and effective discharge for one (Resident #91) of three residents reviewed for discharge. Specifically, the facility failed to have proper documentation to indicate the need to transfer Resident #91 to a COVID-19 facility, document that pertinent resident information was communicated to the receiving facility and provide the receiving facility a copy of the resident's discharge summary to ensure a safe and effective transition of care. This had the potential to affect all residents in the facility. Findings included: A review of the facility's policy and procedure, titled, Transfer or Discharge Documentation, last revised December (year illegible ), indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). When a resident is transferred or discharged from the facility, the discharge transfer form will be completed and sent to the resident. A review of the facility's policy and procedure, titled, COVID-19 Isolation Measures, last revised June 2020, did not indicate a resident was to be transferred out of the facility if they tested positive for COVID-19. A review of the face sheet indicated the facility admitted Resident #91 with diagnoses which included dementia without behaviors, Parkinson's disease, and a traumatic subdural hemorrhage (brain bleed). A review of Resident #91's admission Minimum Data Set (MDS) assessment, dated 09/16/2021, indicated the resident had severely impaired cognitive function with a Brief Interview for Mental Status (BIMS) score of six out of 15. The resident required extensive assistance of one person for activities of daily living (ADLs) including bed mobility, transfer, dressing, toilet use and bathing. During an interview with Resident #91's family member on 12/01/2021 at 5:31 PM, the family member stated the resident was at the facility for rehab and was doing well and the plan was for the resident to be discharged home on [DATE], but when the family member arrived at the facility to pick up the resident, they were no longer at the facility. The family member stated they were told the resident was transferred to another facility several days earlier because the resident tested positive for COVID-19. The family member stated they were never informed that the resident tested positive for COVID-19 and were never told the resident was sent to another facility. The family member stated the facility said it was a lack of communication on their part. A review of a progress notes by the Nurse Practitioner (NP), dated 09/20/2021, indicated the resident was doing well with no concerns from the resident or therapy. The note indicated the social worker was following along for discharge needs and the discharge date was set for 09/24/2021. This was a late entry note that indicated it was created on 10/08/2021 , 18 days after the resident was discharged from the facility. A review of another progress notes by the NP, dated 09/20/2021, indicated the NP was notified that evening that the resident had tested positive for COVID-19 and was being transferred to another facility. The note indicated the resident was asymptomatic upon exam earlier in the day and was stable for transfer to another facility at that time. This was a late entry note that indicated it was created on 10/08/2021, 18 days after the resident was discharged from the facility. The facility provided a xerox copy of two BinaxNOW COVID-19 Ag test cards. One card, labeled 1, had Resident #91's name and room number on the card but was not dated. The second card, labeled 2, had the resident's room number on the card but no name or date. Both cards displayed positive results. A review of a laboratory report indicated Resident #91 was tested for COVID-19 PCR (polymerase chain reaction) on 09/20//2021 and the final results, approved on 09/22/2021, indicated the resident was negative for COVID-19. A review of the resident's electronic health record (EHR) for September 2021 revealed no physician order to transfer the resident to another facility and no discharge summary. There was no other documentation to indicate where the resident was transferred to and if any information was provided to the receiving facility. There was no documentation the resident's family had been notified of the positive COVID-19 test or of the resident being transferred to another facility. There was no documentation to indicate the resident, the resident's family or the receiving facility were notified of the negative COVID-19 results obtained from the lab with a PCR test after the resident was discharged . The discharge order and discharge summary were requested from the Administrator on 11/30/2021 and the Clinical Nurse Consultant on 12/02/2021 and were not provided before the end of the survey. During an interview with Assistant Director of Nursing (ADON) C who was also the infection control preventionist (ICP) on 12/04/2021 at 9:41 AM, ADON C stated Resident #91 was tested the week after admission per the facility policy since the resident was not vaccinated. ADON C stated she was the person that performed the two BinaxNOW COVID-19 Ag test cards in the xerox photocopy the facility had provided. ADON C stated it was always the facility's process to do a second rapid test if the first test was positive. ADON C stated if the second rapid test was positive a sample was sent to the laboratory for a COVID-19 PCR test to be performed. ADON C stated she notified the Administrator and the Director of Nursing (DON) of the positive results and stated she did not recall what happened to the resident after that. ADON C stated the admission liaison would have arranged for the resident to be transferred to a COVID-19 positive facility. ADON C stated she was not aware the resident's PCR test came back negative. ADON C stated she did not know how the facility would handle that situation. An interview with the admission liaison was requested on 12/04/2021 and on 12/06/2021, but they were unavailable. During an interview with the DON on 12/04/2021 at 10:22 AM, the DON stated the facility worked as a team to determine what the best approach was when a resident tested positive for COVID-19, and they had determined it was the best thing for Resident #91 to be transferred to a COVID-19 positive facility. The DON stated the admissions director called facilities to see who could accept the resident at that time. The DON stated they would send the residents information to the facilities so they could review it and decide if they would accept them. She stated once they are accepted, a nurse from their facility would call the receiving facility and give them a report. The DON stated she also communicated with the receiving facility. She stated it should be documented in the progress notes. The DON stated when Resident #91's negative COVID-19 test results came back from the lab, she notified the physician, but they had already sent the resident out. The DON stated she was unsure if there was any communication to the receiving facility about the negative test results. During an interview with Licensed Vocational Nurse (LVN) EE on 12/04/2021 at 11:12 AM, LVN EE stated she called the resident's family and told them the resident had COVID-19 and was being transferred to a different facility. LVN EE stated a family member would normally come in the facility everyday around 5:00 PM so she was waiting for them to come in to tell them, but they did not show up, so she called them instead. LVN EE stated it should have been documented in a progress note, but she could not remember if she documented it or not. She stated the resident was transferred out of the facility after her shift and she did not know which facility the resident went to. During an interview with the Administrator on 12/07/2021 at 8:13 AM, the Administrator stated Resident #91's family was notified by LVN EE when they tested positive for COVID-19 and said there were text messages between the LVN and the DON to prove the family was notified. The facility provided a piece of paper with the title text_0 at the top of it that the DON and LVN EE stated was the text communication between them when Resident #91 was being transferred with a request by the DON to LVN EE for the family to be notified of the positive COVID-19 test and of the resident being transferred. The paper did not indicate the family had been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (Resident #107 and Resident #76) of 31 residents reviewed for care plans. Specifically, the facility failed to have a comprehensive care plan which included Resident #107's transfer status and preferences and Resident #76's assistance with activities of daily living (ADLs). This had the potential to affect all residents. Findings included: 1. A review of the face sheet indicated the facility admitted Resident #107 with diagnoses which included aftercare following joint replacement surgery with the presence of a right artificial knee joint and osteoarthritis. A review Resident #107's admission Minimum Data Set (MDS) assessment, dated 11/20/2021, indicated the resident had no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. A further review of the MDS indicated the resident required extensive assistance of one to two people for activities of daily living (ADLs) including bed mobility, transfers, dressing, toileting, and bathing. The resident was continent of bowel and bladder. During an interview with Resident #107 on 11/30/2021 at 12:29 PM, Resident #107 stated they required a total body mechanical lift (Hoyer) to be transferred out of bed into the wheelchair and back. The resident stated it required two people to transfer with the Hoyer. The resident stated they would prefer to be out of bed before 9:00 AM because they were tired of being in bed so long and back in bed between 6:00 PM and 7:00 PM because they were tired from being up in the wheelchair all day. On 12/01/2021 at 10:15 AM, Resident #107 was observed being transferred from the bed to the wheelchair with the use of a full weight bearing lift (Hoyer) and two staff members. A review of the comprehensive care plan, dated 11/15/2021 and last revised 11/24/2021, revealed the resident did not have a care plan for how to transfer the resident or of the resident's preferences of when to get up and go to bed. During an interview with MDS Coordinators (MDSC TT and MDSC UU) on 12/06/2021 at 11:30 AM, they stated the base line care plan was opened and started by the Director of Nursing (DON) or one of the Assistant Directors of Nursing (ADONs), but the comprehensive care plan was developed after the MDS assessment was completed. MDSC UU stated all ADLs including transfer, bathing, bed mobility, eating and toileting should be care planned. MDSC UU stated if a resident required a mechanical lift for transferring, that should be care planned. After reviewing Resident #107's care plan, she agreed that the resident's transfer status including the use of the Hoyer lift was not care planned. She stated after looking at her notes that she thought the resident was a slide board transfer but agreed that should have been care planned also. MDSC TT stated a resident's preferences should also be care planned. They both stated they were responsible for initiating the comprehensive care plan, but any acute changes were made by the nursing staff on the floor. 2. A review of the face sheet indicated the facility admitted Resident #76 with diagnoses which included a cerebrovascular accident (CVA or stroke). A review of Resident #76's admission Minimum Data Set (MDS), dated [DATE], indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. A further review of the MDS indicated the resident required extensive assistance of one person for ADLs including bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The resident was continent of bowel and bladder. During an interview with Resident #76 on 11/30/2021 at 10:18 AM, Resident #76 stated they required a lot of assistance with their ADLs. Resident #76 stated they had weakness on one side and needed at least one person to assist the resident with toileting, personal care, and bathing. Resident #76 stated therapy was helping the resident get stronger and become more independent, but for now the resident still needed help. A review of the comprehensive care plan, dated 11/11/2021, revealed the resident did not have a care plan for ADLs except for dressing. The care plan did not include what assistance the resident required for the resident's other ADLs. During an interview with Licensed Vocational Nurse (LVN) DD on 12/05/2021 at 1:14 PM, LVN DD stated the MDS staff, or the nurse managers made changes to the care plan. LVN DD stated the nurses on the floor could also make changes if needed. During an interview with MDS Coordinators (MDSC TT and MDSC UU) on 12/06/2021 at 11:30 AM, they stated the base line care plan was opened and started by the Director of Nursing (DON) or one of the Assistant Directors of Nursing (ADONs), but the comprehensive care plan was developed after the MDS assessment was completed. MDSC UU stated all ADLs including transfer, bathing, bed mobility, eating and toileting should be care planned. MDSC UU stated if a resident required a mechanical lift for transferring, that should be care planned. They both stated they were responsible for initiating the comprehensive care plan, but any acute changes were made by the nursing staff on the floor. They both stated they were unsure why the need for ADL assistance for Resident #76 was not care planned. During an interview with the DON on 12/06/2021 at 1:45 PM, the DON stated the residents' ADL status, including transfers, bed mobility, ambulation, dressing, toileting, bathing, and personal care, should be care planned with the appropriate interventions put into place. She stated it was the MDSCs responsibility to initiate the comprehensive care plan based on the MDS assessment but any nurse on the floor could update the care plan with changes. During an interview with the Administrator on 12/07/2021 at 8:13 AM, the Administrator stated care plans should include all pertinent information about how to care for the resident, including how to transfer a resident. The Administrator stated the care plans should be updated with any changes by the nursing staff . A policy and procedure for care plans was requested on 12/03/2021, and the Corporate Nurse Consultant stated the facility followed the RAI (Resident Assessment Instrument) manual which was used to complete the Minimum Data Set (MDS) assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to revise the care plans for three (Resident #71, Resident #111, and Resident #90) of 31 residents reviewed for care plan revision. Specifically, the facility failed to update Resident #71 and Resident #111's care plans with recommendations made from the wound physician, and update Resident #90's care plan with interventions for catheter care. This had the potential to affect all residents. Findings included: A policy and procedure for care plans was requested on 12/03/2021 and the Corporate Nurse Consultant stated they followed the RAI (Resident Assessment Instrument) manual which was used to complete the Minimum Data Set (MDS) assessment. 1. A review of the face sheet indicated the facility admitted Resident #71 with diagnoses which included lung cancer, colon cancer, non-pressure chronic ulcer of the left foot, adult failure to thrive, malnutrition and acute kidney failure. A review of Resident #71's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of six out of 15. Further review of the MDS indicated the resident required extensive assistance of one person for activities of daily living (ADLs) including bed mobility, transfer, toileting and bathing and limited assistance of one person for personal hygiene. The resident was always incontinent of bowel and bladder. The resident had two stage 4 pressure ulcers and one unstageable pressure ulcer upon admission. A review of the comprehensive care plan, initiated 11/10/2021 and last revised 11/17/2021, indicated the resident had pressure ulcers or potential for pressure ulcer development related to mobility limitations, malnutrition, and debility (the care plan indicated to see orders and wound doctor notes). Interventions included the following: administer treatments as ordered and monitor for effectiveness, inform the resident/family/caregivers of any new area of skin breakdown, monitor/document/report PRN (as needed) any changes in skin status, such as appearance, color, wound healing, signs and symptoms of infection, wound size, and stage, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. A review of the initial wound evaluation and management summary by the wound physician, dated 11/12/2021, indicated the resident had eleven wounds that were assessed, three that were classified as pressure wounds. The wound physician recommended the following interventions be implemented: Off-load the wounds, reposition per facility protocol, gel cushion for the chair and a group-2 (air mattress). A review of the comprehensive care plan indicated the care plan was not updated with the recommendations from the wound physician from 11/12/2021. The care plan was revised on 11/17/2021 to include: - Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. - Monitor dressings to ensure it was intact and adhering. Report loose dressing to treatment nurse. A review of the wound evaluation and management summary by the wound physician, dated 11/19/2021, revealed the resident had a new pressure area to the right heel. The wound physician recommended to float heels when in bed and keep legs elevated. A review of the comprehensive care plan indicated the care plan was not updated with the recommendations from the wound physician from 11/19/2021. 2. A review of the face sheet indicated the facility admitted Resident #111 with diagnoses which included diabetes and non-pressure chronic ulcer of the left heel and midfoot, osteomyelitis (an infection in the bone) of the left ankle and foot, peripheral vascular disease (PVD), end stage renal disease (ESRD) with dependence on dialysis. A review of Resident #111's admission Minimum Data Set (MDS) assessment, dated 12/1/2021, indicated the resident had no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. A further review of the MDS indicated the resident required extensive assistance of one to two people for activities of daily living (ADLs) including bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident was occasionally incontinent of bowel and bladder. The MDS indicated the resident had diabetic foot ulcers and an infection of the foot. A review of the comprehensive care plan, dated 11/26/2021, indicated the resident had pressure ulcer or potential for pressure ulcer development. The resident also had potential/actual impairment to skin integrity of the . (no specific location was documented). Interventions included the following: - Administer treatments as ordered and monitor for effectiveness. - Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. - Monitor dressing to ensure it is intact and adhering. Report loose dressing to treatment nurse. - Monitor/document/report as needed (PRN) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. - Weekly treatment documentation to included measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate. - Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. - Encourage good nutrition and hydration to promote healthier skin. - Keep skin clean and dry. Use lotion on dry skin. Do not apply on injury. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. A review of the wound evaluation and management summary by the wound physician, dated 11/30/2021, indicated the resident currently had three wounds that were being monitored. Recommendations were made to elevate the legs and off-load the wounds. A further review of the comprehensive care plan on 12/03/2021 indicated the care plan was not updated with the recommendations from the wound physician. During an interview with Assistant Director of Nursing (ADON) CC on 12/01/2021 at 2:05 PM, ADON CC stated she was the nurse that rounded with the physician and followed up on the recommendations that were made by the wound physician and updated the care plan with those recommendations. She stated she must have missed the order for the treatment to Resident #71's DTI (deep tissue injury) to the left heel or Resident #111's wounds and did not update the care plan with the recommended interventions. ADON CC stated the nurses on the floor were also able to update the resident's care plans with any acute changes. During an interview with Licensed Vocational Nurse (LVN) DD on 12/05/2021 at 1:14 PM, LVN DD stated the MDS staff, or the nurse managers made changes to the care plan. She said the nurses on the floor could also make changes if needed. During an interview with MDS Coordinator (MDSC) TT and MDSC UU on 12/06/2021 at 11:30 AM, they stated the comprehensive care plan was developed after the MDS assessment was complete and they were responsible for that, but acute changes were done by the nursing staff. During an interview with the Director of Nursing (DON) on 12/06/2021 at 1:45 PM, the DON stated the comprehensive care plan was developed by the MDSCs, but any nurse could update the care plan with any changes that needed to be made. She agreed recommendations made by the wound physician would be followed and care planned. The DON stated ADON CC was responsible for doing following up on recommendations made by the wound physician and updating the care plan. 3. A review of Resident #302's face sheet revealed the facility admitted the resident with diagnoses of aftercare following join replacement surgery, infection to internal joint prosthesis, atherosclerotic heart disease, atrial fibrillation, osteoarthritis, and chronic pain. A review of Resident #302's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. According to the MDS, Resident #302 used an indwelling catheter with no bladder training. A review of Resident #302's care plan, dated 04/07/2021, revealed a problem of catheter use with no diagnosis, with a goal of remaining free from catheter-related trauma through review date. No interventions were listed on the care plan . A review of Resident #302's Medication Administration Record (MAR), dated 04/2021, revealed an order to check the Foley (an indwelling urinary catheter) catheter every shift for placement started on 04/07/2021. No diagnosis for the catheter was listed. A review of Resident #302's MAR, dated 04/2021, revealed an order to change the drainage bag as needed for leaking started on 04/06/2021. No diagnosis for the catheter was listed. A review of Resident #302's MAR, dated 04/2021, revealed an order to irrigate the Foley catheter with 30 milliliters (mLs) of normal saline or water as needed for leaking or hematuria started on 04/06/2021. No diagnosis for the catheter was listed. A review of Resident #302's MAR, dated 04/2021, revealed to change 16 French (F) with 30 mL bulb as needed for patency, dislodgement, and leaking. No diagnosis for the catheter was listed. A review of Resident #302's progress notes, dated 04/14/2021, revealed a new order to discontinue the Foley catheter. During an interview on 12/06/2021 at 2:40 PM, Registered Nurse (RN) H stated the Assistant Directors of Nursing (ADON) put orders into the computer for new admissions and were responsible for updating the care plans. During an interview on 12/06/2021 at 2:45 PM, Licensed Vocational Nurse (LVN) L stated the ADONs put orders into the computer for new admissions and were responsible for updating the care plans. During an interview on 12/06/2021 at 2:50 PM, ADON B stated the Director of Nursing (DON) was responsible for updating care plans. During an interview with the Director of Nursing (DON) on 12/06/2021 at 1:45 PM, the DON stated the comprehensive care plan was developed by the MDS Coordinator, but any nurse could update the care plan with any changes that needed to be made. The DON stated ADON CC was responsible for doing following up on recommendations made by the wound physician and updating the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to have an appropriate discharge summary for one (Resident #91) of three residents reviewed for discharge. Specifically, the facility failed to have a discharge summary for Resident #91 that included a recapitulation of the residents stay, a final summary of the resident's status, and a reconciliation of all medications. This had the potential to affect any resident discharging from the facility. Findings included: A review of the face sheet indicated the facility admitted Resident #91 with diagnoses which included dementia without behaviors, Parkinson's disease, and a traumatic subdural hemorrhage (brain bleed). A review of Resident #91's admission Minimum Data Set (MDS) assessment, dated 09/16/2021, indicated the resident had severely impaired cognitive function with a Brief Interview for Mental Status (BIMS) score of six out of 15. The resident required extensive assistance of one person for activities of daily living (ADLs) including bed mobility, transfer, dressing, toilet use and bathing. During an interview with Resident #91's family member on 12/01/2021 at 5:31 PM, the family member stated the resident was at the facility for rehab and was doing well and the plan was for the resident to be discharged home on [DATE] but when the family arrived at the facility to pick up the resident, they were no longer at the facility. The family member stated they were told the resident was transferred to another facility several days earlier because the resident tested positive for COVID-19. The family stated they were never informed that the resident tested positive for COVID-19 and were never told the resident was sent to another facility. The family stated the facility said it was a lack of communication of their part. A review of a progress notes by the Nurse Practitioner (NP), dated 09/20/2021, indicated the resident was doing well with no concerns from the resident or therapy. The note indicated the social worker was following along for discharge needs and the discharge date was set for 09/24/2021. This was a late entry note that indicated it was created on 10/08/2021, 18 days after the resident was discharged from the facility. A review of another progress notes by the NP, dated 09/20/2021, indicated the NP was notified that evening that the resident had tested positive for COVID-19 and was being transferred to another facility. The note indicated the resident was asymptomatic upon exam earlier in the day and was stable for transfer to another facility at that time. This was a late entry note that indicated it was created on 10/08/2021, 18 days after the resident was discharged from the facility. A review of the resident's electronic health record (EHR ) for September 2021 revealed no physician order to transfer the resident to another facility and no discharge summary. There was no other documentation to indicate where the resident was transferred to and if any information was provided to the receiving facility. The discharge order and discharge summary were requested from the Administrator on 11/30/2021 and the Corporate Nurse Consultant on 12/02/2021 and were not provided before the end of the survey. The facility provided a copy of the progress note written by the NP on 09/20/2021 indicating it was the discharge summary. During an interview with Assistant Director of Nursing (ADON) C, who was also the infection control preventionist (ICP), on 12/04/2021 at 9:41 AM, ADON C stated she was not sure who was responsible for completing a discharge summary once a resident was transferred out of the facility. During an interview with the Director of Nursing (DON) on 12/04/2021 at 10:22 AM, she stated the discharge summary was completed by each department manager and included activities, dietary, social services, and nursing. The DON stated Resident #91 was sent out quickly and the staff did not have time to complete a discharge summary before they left but the nurse practitioner had made a note as to why the resident was being sent out. During an interview with Licensed Vocational Nurse (LVN) EE on 12/04/2021 at 11:12 AM, LVN EE stated she did not know who was responsible for completing the discharge summary and did not know what all it needed to include. During an interview with the Administrator on 12/07/2021 at 8:13 AM, the Administrator stated the facility had been working on discharge planning with the resident but then when the COVID-19 test came back positive, the plan had to change. The Administrator stated the discharge summary should have been documented in the resident's record. A policy for discharge summaries was requested on 12/04/2021 from the DON and was not received by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide the care and services needed for one (Resident #71) of one resident reviewed for receiving assistance with activities of daily living (ADLs). Specifically, the facility failed to provide timely incontinent care for Resident #71 and assist Resident #71 to turn and reposition in a timely manner. This had the potential to affect any resident that was dependent on staff for ADL assistance. Findings included: A review of the face sheet revealed the facility admitted Resident #71 with diagnoses which included lung cancer, colon cancer, non-pressure chronic ulcer of the left foot, adult failure to thrive, malnutrition, and acute kidney failure. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident had severe cognitive impairment, with a brief interview for mental status (BIMS) score of six out of 15. Further review of the MDS indicated the resident required extensive assistance of one person for activities of daily living (ADLs), including bed mobility, transfer, toileting, and bathing and limited assistance of one person for personal hygiene. The resident was always incontinent of bowel and bladder. The resident had two stage 4 pressure ulcers and one unstageable pressure ulcer upon admission. A review of Resident #71's comprehensive care plan, last revised 11/17/2021, indicated the resident had an ADL self-care performance deficit. Interventions included: -One person assist with ADL's, transfers, mobility, and toileting/incontinent care. -Encourage the resident to participate to the fullest extent possible with each interaction. -Praise all efforts at self-care. During continuous observations, on 12/02/2021 from 7:59 AM until 11:30 AM, Resident #71 was not provided any type of personal care. The resident was not turned or repositioned or checked for incontinence. The observation revealed the following: At 7:59 AM, Resident #71 was lying on their back in bed with the head of the bed (HOB) up 45 degrees. The over-the-bed table was in front of the resident, with their breakfast tray sitting on top. At 9:00 AM, Resident #71 was in the same position, with their breakfast tray in front of them. At 9:18 AM, an activity staff member entered Resident #71's room and moved the breakfast tray over to the dresser and pulled the over-the-bed table to the side of the bed. The HOB was lowered to approximately 35 degrees. The resident had not been repositioned in the bed, offered toileting, or checked for incontinence. At 10:45 AM, Resident #71 was in the same position but had slid down in the bed so that their feet were hanging off the edge of the bed. The resident had not been repositioned in the bed, offered toileting, or checked for incontinence. At 11:30 AM, Assistant Director of Nursing (ADON) CC was notified of the above observations and the lack of personal care being provided. With the assistance of Certified Nurse Aide (CNA) P, the resident was repositioned up in bed with a pillow placed under their legs to float the heels off the mattress. They did not check the resident for incontinence at that time. During an interview with ADON CC, on 12/02/2021 at 11:30 AM while observing the condition Resident #71 was currently in, ADON CC stated the resident should be checked for incontinence at least every two hours and changed if needed. ADON CC stated she checked Resident #71's adult brief, and it was dry, so the resident did not need to be changed. She stated the resident should also be turned and repositioned at least every two hours. During an interview on 12/02/2021 at 11:50 AM, CNA P stated she did not normally work on the 3rd floor. She stated she thought Resident #17 would call if they needed assistance and that the resident did not need to be repositioned because they were on an air mattress. During an interview on 12/02/2021 at 2:41 PM, the Director of Nursing (DON) stated residents should be assisted to turn and reposition every two hours, but if a resident was on an air mattress, they did not need to be repositioned because the bed did the repositioning for the resident. During an interview on 12/05/2021 at 1:14 PM, Licensed Vocational Nurse (LVN) DD stated an incontinent resident should be checked at least every two hours and changed if needed. LVN DD stated residents should also be reminded and/or assisted to reposition themselves at least every two hours and more often if they had skin integrity issues, even if they were on an air mattress. During another interview on 12/05/2021 at 1:36 PM, the DON stated residents should be offered and assisted to toilet every two hours if they were continent, and if they were incontinent, they should be checked every two hours and changed if needed. A copy of the facility's policy and procedure on providing ADL care was requested from the DON on 12/02/2021 and 12/03/2021 and was not provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide the care and services to prevent the development and delay of healing of pressure ulcers for one (Resident #71) of three residents reviewed for pressure ulcers. This had the potential to affect the five facility identified residents with pressure ulcers and the 29 residents receiving preventative care. Resident #71 was admitted to the facility on [DATE] and, according to the initial nursing evaluation, the resident had wounds to the left knee, multiple wounds on left toes, wounds to left posterior lateral foot, left hip, left upper thigh, sacrum, and left lower back. No description or measurement of the wounds was documented at the time of admission. No assessment was done to determine the resident's risk for pressure injury development. Wound orders were sent from the hospital but were not initiated at the facility. No preventative interventions were initiated. The nutritional assessment did not identify the resident having pressure ulcers. The resident was seen by the wound physician on 11/12/2021 and measurements, descriptions, and recommendations for treatment and interventions were made from the wound physician. The facility implemented the treatment orders, and an air mattress and other recommendations were not implemented. The wound physician identified 11 skin issues, three being pressure related to the sacrum, left lateral ankle, and left lateral foot. The other areas were identified as abrasions or skin tears. The wounds were not documented on by the nursing staff, except for the treatment being done on the skilled administration record (SAR). The resident was seen again by the wound physician on 11/19/2021, and a new deep tissue injury (DTI) was observed to the resident's right heel. Recommendations for skin prep were made with offloading and float heels, and these recommendations were not followed through and initiated. The facility failed to properly assess Resident #71's risk for pressure ulcer development, properly assess existing pressure ulcers, provide recommend treatment to wounds, implement interventions to prevent wound development in a timely manner, follow up on recommendations form the wound physician, and provide an adequate nutritional assessment and supplements for wound healing. These failures resulted in the resident developing pressure ulcers on the bilateral heels and prevented the progression of healing for existing pressure ulcers to the left lateral foot, ankle, and sacrum. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Pressure Ulcers) at a scope and severity of J. These failures placed the facility in an Immediate Jeopardy situation requiring immediate action to be taken to prevent the further decline in resident pressure ulcers and prevent the development of new unidentified pressure ulcers. The facility Administrator and the Corporate Consultant were notified of the Immediate Jeopardy situation and provided the IJ template on 12/03/2021 at 5:42 PM. A Removal Plan was requested. A Removal Plan was accepted and the IJ was determined to be removed on 12/07/2021, after the survey team performed onsite verification, on 12/21/2021, that the Removal Plan had been implemented. Findings included: A policy on pressure ulcer prevention and treatment was requested from the facility on 12/03/2021. The facility provided photocopies from an unnamed nursing textbook on how to care for pressure ulcers which included the following, Comprehensive skin assessment shouldn't be a one-time event limited to admission. Repeat it regularly to determine whether changes in skin condition have occurred. Document a complete skin assessment and interventions use to prevent pressure ulcers. Update the care plan as required. Except for brief periods, avoid raising the head of the bed more than 30 degrees to prevent shearing forces. Apply heel protection devices to prevent heel pressure ulcers. The device should completely offload pressure from the heels. Turn and reposition the patient everyone to two hours or more frequently as required. A review of the face sheet revealed the facility admitted Resident #71 with diagnoses which included lung cancer, colon cancer, non-pressure chronic ulcer of the left foot, adult failure to thrive, malnutrition, and acute kidney failure. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident had severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of six out of 15. Further review of the MDS indicated the resident required extensive assistance of one person for activities of daily living (ADLs) including bed mobility, transfer, toileting, and bathing and limited assistance of one person for personal hygiene. The resident was always incontinent of bowel and bladder. The resident had two stage 4 pressure ulcers (full-thickness skin and tissue loss) and one unstageable pressure ulcer (an ulcer that has full-thickness tissue loss but is either covered by extensive necrotic tissue or by eschar) upon admission. A review of the hospital discharge instructions, dated [DATE], indicated the following: -On sacrum and spine area, apply Venelex ointment twice daily and cover with a foam dressing. -On left great toe, paint with betadine twice daily and leave open to air. -On left lateral foot (more proximal wound), clean with wound cleanser and paint with betadine twice daily and leave open to air. -On scrotum, apply 50/50 mixture of protective ointment and barrier cream twice daily and as needed (PRN) for soiling. -On left knee and left lateral foot (most distal) clean with wound cleanser, apply Aquacell AG (a type of wound dressing) cut to fit and cover with a foam dressing three times a week on Monday, Wednesday, and Friday. -Turn every two hours, using wedges and glide sheet. -Continue to keep heels elevated. A review of the Initial Nursing Evaluation- skin integrity section, dated 11/09/2021, indicated the resident had a wound to the left knee, multiple wounds to the left toes, wounds to the left posterior lateral foot, left hip, left upper thigh, and decubitus (pressure) ulcer to the sacrum, bruises to the bilateral upper extremities, and tiny wounds to the back. A further review of the evaluation revealed no measurements or description of the wounds were documented. A review of the November 2021 computerized physician orders (CPO) indicted Venelex ointment was to be applied to open wounds topically two times a day. The orders did not include dressing orders (what to cover the wounds with after the Venelex was applied). The instructions for wound care from the hospital were not followed. A further review of the orders indicated the resident was to receive Ensure and a house shake with meals. A review of the November 2021 skilled administration record (SAR) revealed the order for the Ensure did not get scheduled and was not documented as being administered. A review of the initial Baseline/Advanced Care Plan, dated 11/09/2021, indicated the resident had pressure ulcers. Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing (no specific frequency was indicated) measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. -Avoid positioning the resident on (no specific location was indicated). -Educated the resident/family/caregiver as to causes of skin breakdown: including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. -Inform the resident/family/caregivers of any new area of skin breakdown. -Monitor dressing (no specific frequency was indicated) to ensure it was intact and adhering. Report lose dressing to the treatment nurse. -Monitor/document/report PRN any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size, stage. -Teach resident/family the importance of changing positions for preventions of pressure ulcers. Encourage small frequent position changes. -The resident needs monitoring/reminding/assistance to turn/reposition at least every two hours, more often as needed or requested. -Treat pain as per orders prior to treatment/turning, to ensure the resident's comfort. -Weekly treatment documentation to include measurement of each are of skin breakdown width length, depth, type of tissue and exudate. A review of the Nutrition Therapy Assessment, dated 11/10/2021, indicated the resident had no pressure injuries and the only supplement listed was Ensure, not the house shake, and recommendations were made to discontinue the order for Ensure. This assessment was completed by the Nutrition and Dietetic Technician, Registered (NDTR) NN and not a Registered Dietitian. A review of the initial wound evaluation and management summary by the wound physician, dated 11/12/2021, indicated the resident had eleven wounds that were assessed, three that were classified as pressure wounds. Wound #1 was an unstageable deep tissue injury (DTI) of the lower sacrum, wound #6 was a stage 4 pressure wound of the left lateral ankle, and wound #7 was a stage 4 pressure wound of the left lateral foot. Wound #1 to the sacrum measured 6.5 centimeters (cm) by 8.0 cm with an unmeasurable depth. The surface area of the wound was 52 cm and was considered a cluster wound with light serous (clear to slightly yellow in color) exudate (drainage). The surrounding tissue was DTI (purple/maroon) in color. The wound bed had 40% granulation (new connective tissue) tissue and 60% skin. The plan was to apply hydrogel with silver and cover with a gauze island dressing with border once daily and recommended to off-load the wound, reposition per facility protocol, have a gel cushion for the chair, and a group-2 mattress (air). Wound #6 to the left lateral ankle measured 2.0 cm by 2.3 cm with an unmeasurable depth. The surface area was 4.6 cm with light serous exudate. The wound bed had 100% slough (dead tissue separating from living tissue), which was surgically debrided to remove necrotic (dead) tissue and establish the margins of viable tissue. The plan was to apply hydrogel with silver and cover with a gauze island dressing with border once daily and recommended to off-load the wound and reposition per facility protocol. Wound #7 to the left lateral foot measured 2.0 cm by 2.1 cm by 0.3 cm. The surface area of the wound was 4.2 cm with light serous exudate. The wound bed had 30% necrotic tissue, 50% slough, and 20% viable tissue and was surgically debrided. The plan was to apply hydrogel with silver and cover with a gauze island dressing with border once daily and recommended to off-load the wound and reposition per facility protocol. According to the November 2021 CPO, the following orders were received on 11/12/2021: -Clean stage 4 pressure wound on the left lateral ankle and left lateral foot with wound cleanser, pat dry, apply hydrogel and cover with dry protective dressing daily. (The order did not specify hydrogel with silver). -Clean unstageable DTI of the lower sacrum with wound cleanser, pat dry, apply hydrogel and cover with dry dressing daily. (The order did not specify hydrogel with silver). -Air mattress every shift. The order for Venelex to open wound twice a day continued with no clarification to indicate what wounds it was to be applied to or what type of dressing it was to be covered with. Review of Resident #71's record revealed no further documentation of the wounds until the resident was seen by the wound physician the following week on 11/19/2021. No weekly skin assessment or wound documentation was completed by the nursing staff. A review of the wound evaluation and management summary by the wound physician, dated 11/19/2021, revealed the resident had a new pressure area, wound #12, an unstageable DTI to the right heel that measured 2.4 cm by 3.7 cm with an unmeasurable depth. The surface area was 8.88 cm. The plan was to apply skin prep to the area once daily, off-load the wound, float heels in bed and elevate legs. A further review of the evaluation indicated wound #1 to the lower sacrum measured 6.5 cm by 7.5 cm with an unmeasurable depth. The surface area was 48.75 cm with light serous exudate. The wound bed had 40% granulation and 60% skin with no change in the treatment plan. Wound #6 to the left lateral ankle measured 2.0 cm by 2.3 cm with an unmeasurable depth. The surface area was 4.6 cm with light exudate. The wound bed had 100% slough and was surgically debrided with no change to the treatment plan. Wound #7 to the left lateral foot measured 2.0 cm by 2.0 cm by 0.3 cm. The surface area was 4.0 cm with light serous drainage. The wound bed had 30% necrotic tissue, 50% slough and 20% viable tissue and was surgically debrided with no change to the treatment plan. A review of the November 2021 CPO revealed no new orders were initiated for wound care to the newly identified pressure area to the right heel (wound #12), and the recommendations for off-loading the wounds, elevating the legs and floating the heels from the wound physician were not being followed. A review of Resident #71's record revealed no further documentation of the wounds until the resident was seen by the wound physician the following week, on 11/26/2021. No weekly skin assessment or wound documentation was completed by the nursing staff. A review of the comprehensive care plan, initiated 11/10/2021 and last revised 11/17/2021, indicated the resident had pressure ulcers or potential for pressure ulcer development related to mobility limitations, malnutrition, and debility (the care plan indicated to see orders and wound doctor notes). Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. -Inform the resident/family /caregivers of any new area of skin breakdown. -Monitor dressings to ensure it is intact and adhering. Report loose dressing to treatment nurse. -Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. -Weekly treatment documentation to include measurement of each area of skin breakdowns width. Length, depth, type of tissue and exudate. The care plan did not include recommendations from the wound physician, including the air mattress, off-loading the wounds, repositioning, elevating the lower extremities, or floating the heels. A review of the wound evaluation and management summary by the wound physician, dated 11/26/2021, indicated wound #1 to the lower sacrum measured 6.5 cm by 6.0 cm with an unmeasurable depth. The surface area was 39 cm with light serous exudate. The wound bed had 40% granulation and 60% skin with hyper-granulation tissue present within the wound margins that was chemically cauterized to facilitate healing. No change was made to the treatment plan. Wound #6 to the left lateral ankle measured 2.0 cm by 2.3 cm with an unmeasurable depth. The surface area was 4.6 cm with light exudate. The wound bed had 100% slough and was surgically debrided. There was no change in the wound progress and no change to the treatment plan. Wound #7 to the left lateral foot measured 2.0 cm by 2.0 cm by 0.3 cm. The surface area was 4.0 cm with light serous drainage. The wound bed had 30% necrotic tissue, 50% slough and 20% viable tissue and was surgically debrided. There was no change in the wound progress and no change to the treatment plan. Wound #12 to the right heel measured 2.4 cm by 3.7 cm with an unmeasurable depth. The surface area was 8.88 cm. There was no change to the wound progress and no change to the recommended treatment plan. A review of the November 2021 CPO revealed the recommendations for the treatment to wound #12 to the right heel were not initiated again for the second week. A review of the comprehensive care plan revealed it was not updated with the recommendations from the wound physician for the second week. A review of the record revealed no further documentation of the wounds until observations were made by the surveyor on 12/01/2021 (see below). No weekly skin assessment or wound documentation was completed by the nursing staff. A review of a progress notes by the infectious disease nurse practitioner (IDNP), dated 11/28/2021, indicated the resident had multiple wounds in different stages of healing, including two open wounds to the lateral foot with erythema (reddening) around both wound with a question of possible arterial problem and need for an arterial doppler. The note indicated the resident was to be started on doxycycline (an antibiotic) orally for ankle wounds and sacrum wound that was a DTI with a small opening that had erythema around it. (This progress note was a late entry done on 12/03/2021 at 11:32 AM after being requested from the surveyor after observations of wound care were done with the wound physician and IDNP). The arterial doppler was not ordered until 12/03/2021. A review of the December 2021 CPO indicated an order was put in on 12/01/2021 for bilateral heel protectors to be on while in bed every shift. The recommendations for treatment to the right heel, wound #12, from the wound physician were still not initiated. Observations during wound care for Resident #71 on 12/01/2021 at 2:05 PM performed by the Assistant Director of Nursing (ADON) CC and Registered Nurse (RN) H revealed the resident had three new wounds that were not identified previously by the facility, including a deep tissue injury (DTI) to the left heel, the DTI to the right heel (previously identified by the wound physician) and a scab to the right great toe. ADON CC stated she was the nurse that rounded with the wound care physician, and she thought the DTI to the right heel was new (even though it had been identified by the wound physician two weeks earlier on 11/19/2021). The resident had inflatable heel protectors in place and was lying on an air mattress. The ADON contacted the physician and got orders to discontinue the heel protectors and initiated floating the resident's heels and skin prep to be applied to the newly identified wounds. A review of the December 2021 CPO indicated there were new orders as of 12/01/2021 to discontinue the heel protectors and begin offloading bilateral heels while in bed and to apply skin prep to the DTIs on the bilateral heels daily after cleansing with wound cleanser. A further review of the orders revealed the order for the house shakes with meals was discontinued on 12/01/2021, and the Venelex ointment was discontinued on 12/01/2021. A review of a nursing progress note, dated 12/01/2021, indicated a DTI was found to the left heel and right great toe during wound care, and the nurse noticed the inflatable heel protectors were not inflating well. Orders were obtained to discontinue the protector boots and start elevating the bilateral heels on pillows and off-load the heels while in bed. A review of a weekly pressure ulcer evaluation, dated 12/01/2021, indicated the resident had a pressure area to the left heel that developed 12/01/2021 and was described as a deep tissue injury (DTI) that was dark red/purple in color. No measurements were documented. (This was the only weekly pressure ulcer evaluation found in the resident's record for any of the pressure ulcers the resident had). A review of a progress notes by the infectious disease nurse practitioner (IDNP), dated 12/01/2021, indicated the resident was currently on doxycycline (an antibiotic) orally for ankle wounds and a sacrum wound that was a DTI with a small opening that had erythema around it. The note indicated the IDNP discussed off-loading the resident's heels with the nurse and that pillows were under the heels. (This progress note was a late entry done on 12/03/2021 at 11:40 AM after being requested from the surveyor after observations of wound care were done with the wound physician and IDNP). Observations on 12/02/2021 at 7:59 AM revealed Resident #71 was lying in bed on their back with the head of the bed elevated greater than 45 degrees. The resident was wearing the inflatable heel protectors with the sheet pulled tightly across the resident's feet. Continuous observations were done from 7:59 AM until 11:30 AM. The resident was not provided any care during that time, including repositioning or incontinent care. The resident slowly slid down in the bed until their feet were off the edge of the bed. During an observation and interview with ADON CC, on 12/02/2021 at 11:30 AM while observing the condition Resident #71 was currently in, she stated the inflatable heel protectors should not have been on because they were causing increased pressure to other parts of the resident's legs. The ADON removed the inflatable heel protectors, and a new DTI was observed on the resident's left lateral lower leg. The ADON stated the resident's heels should be floated with pillows and the resident's position should be changed at least every two hours. The ADON stated she was going to put an order in the system for the resident to be turned and repositioned every two hours and was going to obtain an order for skin prep to be applied to the new DTI on the left lateral lower leg. With the assistance of Certified Nurse Aide (CNA) P, the resident was repositioned up in the bed with a pillow placed under their legs to float the resident's heels off the mattress. ADON CC educated CNA P to reposition the resident at least every two hours using pillows to off-load pressure to the resident's wounds. During an interview on 12/02/2021 at 11:50 AM, CNA P stated she did not normally work on the 3rd floor. She stated she thought Resident #71 would call if they needed assistance and that the resident did not need to be repositioned because they were on an air mattress. A review of a nursing progress note, dated 12/02/2021, indicated the wound physician was contacted about the DTI found on the left lower leg, and new orders were obtained to apply skin prep daily and turn the resident every two hours. The note indicated the staff was informed to monitor and turn the resident every two hours. During an interview on 12/02/2021 at 2:41 PM, the Director of Nursing (DON) stated if a resident was on an air mattress, they did not need to be repositioned because the bed did the repositioning for the resident. The DON stated the facility wounds were monitored during wound care and documented on the skilled administration record (SAR). The DON stated if there was a change in the wounds, the nurse would contact the physician and get new orders. The DON stated the facility should have followed the wound care orders received from the hospital for Resident #71, and the air mattress should have been implemented immediately. She stated she was unsure why that did not happen. She stated the wound physician came twice a week. The DON stated that on Tuesdays the wound physician saw any newly admitted residents or residents with newly identified wounds and saw all other wounds on Fridays. The DON stated ADON CC did rounds with the wound physician and was responsible to follow up on any recommendations made. A review of the December 2021 CPO indicated orders were entered on 12/02/2021 for a sitting program three times a day, for the resident to be turned every two hours while in bed, and for skin prep to be applied to the wound to the left lateral lower leg. Observations on 12/03/2021 at 8:15 AM revealed Resident #71 was lying on their left side with their heels directly on the mattress. The wound physician was in to see the resident at 10:05 AM and identified a total of five new skin issues since the last visit (11/26/2021). The new areas were a DTI to the left heel, a scabbed areas to the right great toe, the left great toe (distal to the previous wound), the tip of the 3rd left toe, and a DTI to the lateral left lower leg. The DTI to the right heel opened and the wound physician debrided the wound, removing the top layer of skin. The wound physician attempted to debride the wound to the left lateral foot after applying benzocaine to numb the area, but the resident was not able to tolerate the pain associated with the procedure. The wound physician stated they were concerned the resident had arterial venous problems that was causing the delay of wound healing and the development of new wounds and was ordering a doppler study to be done, even though pulses were felt in the resident's feet. The wound physician was not aware the resident was not being followed by the dietitian and thought the resident was on a supplement for wound healing. The wound physician stated that if the staff had been following the recommendations, it was less likely for the resident to develop new areas. They stated the resident still needed to be repositioned, even if they were on an air mattress, and the staff needed to make sure direct pressure was not being applied to the existing wounds. The infectious disease nurse practitioner (IDNP) was also present during the wound rounds with the wound physician. She stated she started the resident on an antibiotic for the wounds to the left lower extremity, not the sacrum, and they were started because there was a delay in healing. She acknowledged that a progress note indicating the need for the antibiotic had not been entered and stated one would be done for the 11/28/2021 visit and the 12/03/2021 visit. A review of the wound evaluation and management summary by the wound physician, dated 12/03/2021, indicated wound #1 to the lower sacrum measured 6.5 cm by 6.0 cm with an unmeasurable depth. The surface area was 39 cm with light serous exudate. The wound bed had 40% granulation and 60% skin. There was no change to the wound progress and no change to the treatment plan. Wound #6 to the left lateral ankle measured 2.8 cm by 2.5 cm with an unmeasurable depth. The surface area was 7 cm with light serous exudate. The wound bed had 50% slough and 50% granulation tissue and was surgically debrided. There was deterioration in the wound progress and no change to the treatment plan. Wound #7 to the left lateral foot measured 2.0 cm by 1.5 cm by 0.3 cm. The surface area was 3.0 cm with light serous drainage. The wound bed had 30 % necrotic tissue, 50% slough, and 20% viable tissue and was surgically debrided. There was improvement with the wound progress and no change to the treatment plan. Wound #12 to the right heel measured 3.0 by 3.0 cm with an unmeasurable depth. The surface area was 9.0 cm. The wound was surgically debrided, and the treatment plan was to apply hydrogel with silver and cover with a gauze island dressing with a border daily, off-load the wound, float heels in bed, and elevate legs. The wound physician classified the wound to the resident's left heel (Wound #16) as an arterial wound that measured 3.0 cm by 4.0 cm with no measurable depth. The surface area was 12 cm and was 99% skin with a fluid filled blister and dried fibrinous exudate (scab). The plan was for skin prep to be applied daily, elevate legs, and off-load the wound. The wound physician classified the wound to the left lateral leg as an arterial wound that measured 9.5 cm by 1.0 cm with an unmeasurable depth. The surface area was 9.5 cm and was 99% skin with dried fibrinous exudate (scab). The plan was to apply skin prep daily, elevate the legs and off-load the wound. A bilateral lower extremity arterial doppler was recommended. A review of the progress notes by the IDNP, dated 12/03/2021, indicated the resident had a new cluster of wounds on the left lateral lower extremity and recommended to continue the doxycycline for now and order an arterial doppler. A review of the December 2021 CPO revealed updated orders were received on 12/03/2021 to include: -Clean stage 4 pressure wound to left lateral wound with wound cleanser, pat dry and apply hydrogel with silver and cover with a dry Opti-foam dressing daily at bedtime. -Cleanse wound to sacrum with wound cleanser and pat dry with 4 x 4 gauze. Apply hydrogel with silver and cover with a gauze border dressing at bedtime. -Cleanse unstageable right heel wound with wound cleanser and pat dry with 4 x 4 gauze. Apply hydrogel with silver and cover with a gauze island border dressing daily. Offload heels in bed. -4 ounces house shake with meals for wound care. -Multivitamin one tablet daily. -Vitamin C 500 milligrams (mg) twice daily. -Arterial doppler to bilateral lower extremities. The wound orders for the stage 4 pressure wound to the left lateral ankle did not include the hydrogel with silver as recommended by the physician. A review of the radiology interpretation of the findings of the bilateral lower extremity Doppler arterial ultrasound, dated 12/03/2021, indicated the resident had findings consistent with severe peripheral arterial disease (PAD). These results indicate the resident was at an even higher risk for wound development without preventative interventions being implemented. According to a nursing progress note, dated 12/03/2021 at 9:37 PM, the resident's doppler results were shared with the wound physician and, according to the results, the resident had severe arterial disease, the wounds were arterial in nature, and the resident required a vascular consult. A review of the comprehensive care plan, last revised 11/17/2021, was not updated with interventions to prevent the resident from developing new pressure areas or to aide in the healing of existing pressure ulcers. A review of the manufacturer's instructions from Direct Supply for the Panacea Air Max mattress Resident #71 was lying on indicated the product was only one element of care in the prevention and treatment of pressure ulcers and was not designed to and cannot replace good care-giving practices and treatment including, but not limited to, appropriate nutrition and hydration, frequent positioning, routine skin assessment, wound treatment, infection control, and other generally accepted standards of care and prevention. During an interview on 12/05/2021 at 1:14 PM, Licensed Vocational Nurse (LVN) DD stated residents should also be reminded and/or assisted to reposition themselves at least every two hours and more often if they had skin integrity issues, regardless if they were on an air mattress or not. During an interview on 12/07/2021 at 8:16 AM, the Administrator stated she received a report of the all the facility wounds weekly that included measurements and description. This report was requested from the Administrator at that time and was not provided. The Administrator stated a facility-wide skin audit had been done the day before, and no new skin issues were identified. The facility Administrator and the Corporate Consultant were notified of the Immediate Jeopardy situation and provided the IJ template on 12/03/2021 at 5:42 PM. The facility submitted a Removal Plan on 12/06/2021 at 11:13 AM. Removal Plan: A facility wide skin audit of all residents at risk was completed by the clinical team for possible similar failures found in the survey. The skin assessments were reviewed for accuracy by the clinical team and if required, update the care plan as needed. This was completed 12/04/2021. Effective 12/04/2021, the Director of Nursing (DON) or designee will review current resident skin assessments for completion and accuracy and review and implement nutritional recommendations upon approval from the Medical Doctor (MD). MD recommendations given for skin and nutrition will be reviewed by the DON or designee to[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to provide a safe environment and proper supervision to prevent falls for one (Resident #111) of two residents reviewed for falls. Specifically, the facility failed to implement effective interventions to prevent Resident #111 from falling or prevent injuries from occurring if the resident did fall . This had the potential to affect any resident's that were at a high risk for falls and resident's that had fallen. Findings included: A review of the facility's policy and procedure, titled, Fall Risk, last revised 06/2019, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will identify appropriate interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of category of falling. A review of the face sheet indicated the facility admitted Resident #111 with diagnoses which included chronic osteomyelitis (bone infection) of the left ankle and foot with ulcer, end stage renal disease (ESRD) with dependence on dialysis, polyneuropathy (damage of the peripheral nerves), and generalized muscle weakness with difficulty in walking. A review of the admission Minimum Data Set (MDS), dated [DATE], indicated the resident had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. A further review of the MDS indicated the resident required extensive assistance of one to two people for activities of daily living (ADLs), including bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident had one fall prior to admission and one fall without injury since admission. A review of the Fall Risk Evaluation, dated 11/24/2021, revealed the resident was a low risk for falls with a score of nine. A further review of the evaluation indicated a score of 10 or greater was a high risk for falls. A review of the comprehensive care plan, dated 11/26/2021, indicated the resident was at risk for falls (it did not specify high, moderate, or low as indicated). Interventions included: -Anticipate and meet the resident's needs. -Be sure the call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Ensure that the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. (It did not specify and describe the correct footwear being used as indicated, i.e., brown leather shoes, tartan bedroom slippers, black non-skin socks). -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team (IDT) as to causes. -The resident needs a safe environment with: (It did not specify as indicated, i.e., even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light; bed in low position at night; side rails as ordered; handrails on walls; and personal items within reach). A review of an incident report, dated 11/28/2021 at 11:00 AM, indicated the resident was found sitting on the floor next to the bed with no apparent injury, and the resident stated they were attempting to get out of bed and slipped and fell on the floor. The report indicated the resident was encouraged to call for help at all times. The section of the report for the resident's mental status, level of pain, and predisposing factors was incomplete, with no information documented. The incident report was not part of the resident's EHR. No new interventions were initiated to prevent the resident from falling again, and the care plan was not updated following the 11/28/2021 fall. There was no documentation in the progress notes of the resident being monitored after the fall occurring on 11/28/2021. During an interview on 11/30/2021 at 12:16 PM, Resident #111 stated they were at the facility because they had an infection in their foot and their neuropathy was getting worse, making it hard for them to care for themselves, so they were there for therapy to get stronger. The resident stated they had fallen three times since they were admitted to the facility. The resident stated they did not get hurt physically, just their pride. Resident #111 stated they could not remember what happened the first two times but stated the last time they just slid off the edge of the bed, and the staff had to come help them get up off the floor. A review of Resident #111's electronic health record (EHR), on 11/30/2021, revealed no documentation of the resident falling. During observations on the 3rd floor [NAME] Hall on 12/02/2021 at 10:10 AM, Resident #111 was sitting in the upright chair in the resident's room. At 10:19 AM, Resident #111 could be heard yelling for help from the end of the hallway. At 10:20 AM, Registered Nurse (RN) H was told Resident #111 was on the floor in the resident's room. Resident #111 could be seen lying face down on the floor in front of the chair with a pool of blood under the resident's head. The resident was transferred out of the facility via emergency medical services (EMS) at 10:46 AM for further evaluation. A review of a nursing progress note, dated 12/02/2021 at 10:30 AM, indicated the resident was found on the floor, face down, screaming that they hit their head on the floor. The note indicated the resident stated they fell out of the chair when trying to transfer to the bed. The note indicated the call light was within reach, but the resident did not use it. The note indicated the resident had a cut on the forehead, the right arm was bleeding, and the resident's oxygen saturation was 66% initially because the resident had knocked their oxygen tubing off, but it came up to 90% once it was replaced. The note indicated the resident was taken to the emergency room. A review of a nursing progress note, dated 12/02/2021 at 1:21 PM, indicated the resident returned from the hospital in stable condition, and all tests run at the hospital were negative. A review of the incident report, dated 12/02/2021 at 12:12 PM, indicated the same information documented on the progress note was on the report with no additional information. The report indicated there were no predisposing environmental or situation factors, and gait imbalance was a predisposing physiological factor. It indicated the resident was a fall risk, required assist of one, and did not use the call light. No new interventions were initiated to prevent the resident from falling again or to keep the resident from getting injured if they did fall. A review of the comprehensive care plan, revised 12/03/2021, indicated the only update to the care plan was indicating the resident was a low risk for falls and the removal of the words specify and describe the client footwear and specify safe environment. No new interventions were initiated. During an interview on 12/02/2021 at 10:37 AM, Assistant Director of Nursing (ADON) CC stated Resident #111 was alert and oriented and attempted to transfer on their own and fell this morning. She stated the call light was within reach, but the resident chose not to use it, so they fell. The resident received a laceration on the head, so ADON CC advised the floor nurse to send the resident to the emergency for further evaluation. ADON CC stated all they could do was remind the resident to ask for assistance. During an interview on 12/02/2021 at 10:55 AM, Certified Nurse Aide (CNA) P stated she had not heard of Resident #111 falling prior to that day and was not aware of any fall prevention interventions being in place. She stated the resident was alert and oriented and could do a lot of things unassisted but got weaker after dialysis and required more assistance. During an interview on 12/05/2021 at 1:36 PM, the Director of Nursing (DON) stated most of the residents that came to the facility were alert and oriented, and they tried to encourage them to be safe. The DON stated that if a resident did fall, then interventions should be initiated but it depended on the resident to determine what type of interventions. The DON stated sometimes a fall was just an accident, and there was nothing to do to prevent it. She stated some interventions, such as floor mats or the bed being in low position, could be a hazard if the resident was mobile. The DON stated every resident got non-slip socks in their welcome package, and they encouraged the residents to wear them when they were not wearing their shoes. She stated Resident #111 was encouraged to wear the non-slip socks after the first fall on 11/28/2021 and that it was care planned. She stated when Resident #111 fell the second time, the call light was in reach, but the resident did not use it. The resident was wearing the non-skid socks while self-transferring. The DON stated they could not use a floor mat or low bed because the resident was mobile. The DON stated there was not much they could do, because they could not restrict the resident's movement. The DON stated all falls were reviewed in morning meeting with therapy, and the care plan was updated after each fall by each discipline. She stated the care plan could also be updated by any nurse on the floor. During an interview on 12/07/2021 at 8:13 AM, the Administrator stated when a resident was alert and oriented and chose not to request assistance from the staff, there was not a lot of interventions the facility could do to prevent further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter was assessed for removal as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for one (Resident #302) of two residents reviewed for catheter use. This deficient practice had the potential to affect the two residents in the facility with a catheter. Findings included: A review of Resident #302's face sheet revealed the facility admitted the resident with diagnoses of aftercare following joint replacement surgery, infection to internal joint prosthesis, atherosclerotic heart disease, atrial fibrillation, osteoarthritis, and chronic pain. A review of Resident #302's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS further revealed Resident #302 used an indwelling catheter with no bladder training. The resident was no longer residing in the facility. A review of Resident #302's care plan revealed a problem of catheter use with no diagnosis, dated 04/07/2021, with a goal of remaining free from catheter-related trauma through review date. No interventions were listed on the care plan. A review of Resident #302's Medication Administration Record (MAR), dated April 2021, revealed an order to check Foley (an indwelling urinary catheter) catheter every shift for placement started on 04/07/2021. No diagnosis for the catheter was listed. A review of Resident #302's MAR, dated April 2021, revealed an order to change drainage bag as needed for leaking started on 04/06/2021. No diagnosis for catheter was listed. A review of Resident #302's MAR, dated April 2021, revealed an order to irrigate Foley catheter with 30 milliliters (mLs) of normal saline or water as needed for leaking or hematuria started on 04/06/2021. No diagnosis for the catheter was listed. A review of Resident #302's MAR, dated April 2021, revealed change 16 French (F) with 30 mL bulb as needed for patency, dislodgement, and leaking. No diagnosis for the catheter was listed. A review of Resident #302's progress notes, dated 04/14/2021, revealed a new order to discontinue the Foley catheter. During an interview on 12/04/2021 at 11:20 AM, the Director of Nursing (DON) stated Resident #302 came from the hospital, and they (referring to the hospital) could start a catheter for any reason. The DON thought Resident #302 wanted a catheter because the resident did not want to wet themself, so the catheter was for dignity reasons. The DON then stated there needed to be an appropriate diagnosis to have a catheter. During an interview on 12/04/2021 at 12:05 PM, Registered Nurse (RN) QQ stated if a resident was admitted with a catheter, they would check the medical record to find out why. If a resident had no diagnosis or any reason as to why they had a catheter, they would contact the physician to discontinue the orders and remove the catheter. The catheter should be removed the day of admission or the next day after admission. RN QQ stated it was important to remove a catheter if a resident had no diagnosis because catheters could cause urinary tract infections (UTIs). During an interview on 12/04/2021 at 12:17 PM, Licensed Vocational Nurse (LVN) HH stated if a resident had a catheter, the resident must have a diagnosis such as neurogenic bladder or urine retention. If there was no diagnosis for a catheter order, the LVN communicated with the physician for an order to remove it. LVN HH stated it was important to not place a catheter if there was no diagnosis, because catheters can introduce infections and be uncomfortable for the patient. During an interview on 12/04/2021 at 12:22 PM, RN II stated they would call the physician if a resident had a catheter with no diagnosis. RN II stated the nursing staff needed to know why a resident had a catheter if one was placed. RN II stated a resident's catheter should be removed as soon as possible after admission. RN II further stated they had not seen a resident use a catheter for dignity reasons because they did not want to wet themself. RN II stated it was important to remove a catheter if it was not needed to prevent infection. During an interview on 12/04/2021 at 2:00 PM, the DON stated they thought Resident #302 had a catheter for dignity reasons because there was no proper diagnosis for the catheter. The DON further stated it was important to make sure there was a proper diagnosis for the catheter to prevent infection. During an interview on 12/04/2021 at 4:50 PM, the Administrator stated nursing should not use a urinary catheter for incontinence convenience. Residents should have a diagnosis for catheter use. On 12/04/2021, the facility provided two undated photocopied pages from an unknown textbook on catheter use and removal when asked for the facility's catheter use policy. Pertinent information from the photocopied pages from the textbook indicated, Catheters are often inserted for inappropriate indications. The need for the catheter should reviewed daily, and it should be removed as soon as it's no longer needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to act upon the pharmacist's monthly Medication Regimen Review (MRR) for two (Resident #109 and Resident #135) of five residents reviewed for unnecessary medications. This deficient practice had the potential to affect 30 residents receiving psychoactive medications. Findings included: 1. A review of Resident #109's face sheet revealed the facility admitted the resident with diagnoses of a femur fracture, type two diabetes mellitus, atrial fibrillation (irregular heartbeat), congestive heart failure, and acute kidney failure. A review of Resident #109's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of Resident #109's MDS, dated [DATE], revealed Resident #109 received an anticoagulant (blood thinner) in the seven days prior to the assessment and a hypnotic medication in the three days prior to the assessment. A review of Resident #109's Medication Administration Record (MAR), dated November 2021, revealed an order for warfarin sodium tablet 2 milligrams (mg) started on 11/20/2021. Give one tablet by mouth (po) once a day for a blood thinner with 5 mg to equal 7 mg total. A review of Resident #109's MAR, dated November 2021, revealed an order for warfarin sodium tablet 5 mg started on 11/21/2021. Give one tablet by mouth once a day for a blood thinner with 2 mg to equal 7 mg total. A review of Resident #109's MAR, dated November 2021, revealed an order for zolpidem 10 mg started on 11/20/2021. Give one tablet by mouth once a day as needed for insomnia at bedtime only. A review of Resident #109's MAR, dated November 2021, revealed an order for trazodone 50 mg tablet started on 11/20/2021. Give one tablet by mouth at bedtime for insomnia. A review of Resident #109's care plan revealed a problem of using sedative/hypnotic therapy related to sleeplessness initiated on 11/22/2021. Interventions initiated on 12/01/2021 included to monitor and document any side effects and effectiveness every shift. A review of Resident #109's care plan revealed a problem of using an anticoagulant therapy related to atrial fibrillation initiated on 11/22/2021. Interventions initiated on 12/01/2021 included to monitor and document any side effects and effectiveness every shift. A review of Resident #109's MRR, dated 11/22/2021, revealed a recommendation for anticoagulant monitoring for warfarin and behavior and side effect monitoring for sedative/hypnotic use for the trazodone and the zolpidem. A review of Resident #109's MAR, dated November 2021, revealed no anticoagulant monitoring or behavior and side effect monitoring for the sedative/hypnotic use. During an interview on 12/01/2021 at 12:15 PM, Registered Nurse (RN) D stated a resident who was on a blood thinner should be on anticoagulant monitoring for any bleeding or other adverse effects. RN D further stated any residents with orders for an anticoagulant or behavior/side effect monitoring for sedative use should have been documented on the MAR. RN D further stated Resident #109 did not have any monitoring orders on the MAR. 2. A review of Resident #135's face sheet revealed the facility admitted the resident with diagnoses of insomnia, depression, cerebral infarction (stroke), and obstructive sleep apnea (breathing obstruction). A review of Resident #135's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. A review of Resident #135's MDS, dated [DATE], revealed Resident #135 received an antidepressant and hypnotic medication in the seven days prior to assessment. A review of Resident #135's Medication Administration Record (MAR), dated November 2021, revealed an order for desvenlafaxine succinate extended release (ER) tablet 50 milligram (mg) started on 11/20/2021. Give one tablet per day for depression. A review of Resident #135's MAR, dated November 2021, revealed an order for temazepam capsule 30 mg started on 11/19/2021. Give one capsule at bedtime for insomnia. A review of Resident #135's MAR, dated November 2021, revealed an order for alprazolam tablet 0.5 mg started on 11/19/2021. Give one tablet at bedtime as needed for anxiety. A review of Resident #135's care plan revealed a problem of using an antidepressant medication related to depression, dated 11/22/2021. Interventions included to administer the medication as ordered by physician, monitor and document side effects, effectiveness, and any adverse reactions every shift. A review of Resident #135's care plan revealed a problem of using a sedative/hypnotic medication related to insomnia dated 11/30/2021. Interventions included to administer the medication as ordered by physician, monitor and document side effects, effectiveness, and any adverse reactions every shift. A review of Resident #135's MRR, dated 11/22/2021, revealed a recommendation for anti-anxiety behavior and side effect monitoring for alprazolam, sedative/hypnotic behavior and side effect monitoring for temazepam, and antidepressant side effect monitoring for desvenlafaxine. A review of Resident #135's MAR, dated November 2021, revealed no anti-anxiety, sedative/hypnotic, or antidepressant behavior and side effect monitoring. During an interview on 12/02/2021 at 12:15 PM, Registered Nurse (RN) G stated if a resident had any medication behavior or side effect monitoring, it would be on the MAR, and nurses would be triggered to document on the MAR whether a resident was having any behaviors or medication side effects. RN G further stated Resident #135 had no order for medication monitoring in place on the MAR. During an interview on 12/01/2021 at 12:58 PM, the Director of Nursing (DON) stated the pharmacist did MRR's two or three times a month and sends recommendations to the ADON to follow up on. If the recommendation needed a physician's order, it would be sent to the physician; otherwise, the ADON would make the adjustment in the medical record. The DON then stated nursing should make any simple changes immediately in the medical record, but if the recommendation needed to be sent to the physician, it may take two or three days to complete. The DON stated no pharmacy recommendations should take longer than that. The DON further stated Resident #135 had no order for medication monitoring in place. During an interview on 12/01/2021 at 2:35 PM, the Assistant Director of Nursing (ADON) stated the pharmacist emailed their recommendations, and the ADON immediately put the orders in the computer unless the recommendation needed to be sent to the physician. The ADON further stated if a recommendation such as behavior or side effect monitoring was recommended, the order should be put in the medical record within one day. The ADON then stated Resident #135 had no order for medication monitoring in place because the Pharmacist's recommendations were not yet acted upon. The pharmacist was called on 12/03/2021 and 12/04/2021 with no answer. The surveyor was unable to leave a message on the number provided. During an interview on 12/03/2021 at 1:00 PM, the Administrator stated pharmacy recommendations should be followed. The Administrator expected nursing to contact the physician with recommendations and let the physician decide whether to make any medication changes. The Administrator further stated it was important to follow pharmacy recommendations because if the pharmacist felt like something was an issue, nursing should at least give the physician an opportunity to look at the medication and make a decision on whether to make any changes. A review of the facility's Consultant Pharmacist Services and Reports policy, dated 10/01/2019, revealed the consultant pharmacist recommendations regarding residents' medication therapy were communicated, implemented, and responded to in an appropriate and timely fashion. Recommendations were acted upon and documented by facility staff.

Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5%. Three medication administration errors were identified out of 33 opportunities for errors, yielding a 9.09% error rate. LVN L failed to administer Aspart insulin as per order to control blood glucose levels for Resident #112. RN I did not administer the correct dose of Baclofen to Resident #24 and held carvedilol against physician's order. This deficient practice had the potential to lead to the wrong administration of medication to residents, mismanagement of care, adverse effects, and physical harm. Findings included: 1. A review of Resident #112's medication orders dated 11/24/2021, indicated the resident was to receive Aspart insulin per sliding scale before meals and at bedtime, with the next blood glucose level to be taken at 7:30 AM . On 12/02/2021 at 7:59 AM, Licensed Vocational Nurse L (LVN L) was observed preparing medications to administer to Resident #112. LVN L informed the resident which medications were being administered and the resident agreed and self-administered the medications . On 12/02/2021 at 7:59 AM, LVN L was interviewed and stated the Aspart insulin could not be administered because the glucose level had not been checked as ordered. LVN L stated the resident had not yet received breakfast and would need to check the blood sugar before the resident ate. A review of the medication administration audit report (MAAR) for 12/02/2021, indicated LVN I administered the Aspart insulin at 9:08 AM. During a follow up interview on 12/02/2021 at 9:30 AM, LVN L confirmed the blood glucose was checked after the resident ate breakfast. LVN L stated Aspart 2 units was given at 9:08 AM after the resident ate breakfast. 2. A review of Resident #24's medication orders dated 11/26/2021, indicated the resident was to receive Baclofen 15mg (three 5mg tablets) and carvedilol 6.25 mg one tablet, hold if SBP <110 or HR<60. On 12/02/2021 at 9:17 AM, Registered Nurse I (RN I) was observed preparing medications to administer to Resident #24. The medications included Baclofen 5 mg, one tablet. RN I stated carvedilol 6.25mg one tablet would not be given because the resident's diastolic blood pressure was 57. On 12/02/2021 at 9:40 AM, RN I was interviewed about the medication observation. After RN I reviewed the order, RN I stated two more tablets of the Baclofen 5mg needed to be administered because only 5mg was given. RN I stated the parameters for carvedilol did not indicate the medication needed to be held. During an interview on 12/03/2021 at 1:30 PM, the Regional Clinical Consultant (RCC) stated medications were to be administered according to the physician's orders. A review of the facility's policy titled Oral Medication Administration dated 10/01/2019, indicated the procedure for administering medications included, Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medications to each resident. Review medication administration record for any tests or vital signs that need to be determined prior to preparing the medications.

Based on observation, interview, and policy review, the facility failed to ensure emergency medications kits (E-kits) were sealed and the inventory sheet updated after the opening/removal of a medication for 1 out of 3 medication storage rooms (1st floor medication storage room). This deficient practice had the potential to result in unaccounted for medications, a lack of emergency medication availability, and a misuse of emergency medications. Findings included: During a concurrent first-floor medication storage room observation and interview on 12/01/2021 at 2:15 PM, the E-Kit was observed to be unlocked. RN (Registered Nurse) N opened the E-Kit and stated a lock should be in place but was not sure who opened the E-Kit or when. RN N stated it was important to keep an accurate inventory of all medication to ensure nothing was missing. During a concurrent first-floor medication storage room observation and interview on 12/01/2021 at 2:45 PM, the E-Kit in the first-floor medication storage room remained unlocked. Assistant Director of Nursing (ADON) B stated the E-kit should have a red tag to alert staff it had been opened and needed to be restocked by pharmacy. The ADON confirmed the inventory sheet inside the E-Kit did not have any documentation of when the E-Kit was opened or what was removed. The ADON stated the E-Kits must be locked to ensure all medications were accounted for and available for use in case of an emergency. The ADON stated the medications in the E-Kits were for emergency use, and if a medication was not available it could delay emergency care. During an interview on 12/04/2021 at 11:25 AM, the DON stated E-kits had to be locked and the inventory sheet updated. The DON stated if an E-Kit was opened, a red tag had to be applied and the E-Kit sealed until the pharmacy restocked it. The DON stated the nurses were responsible for informing the pharmacy an E-Kit was opened. A review of the facility's policy titled, Remote Medication Kits (Emergency Kits) & Controlled (Narcotic) Kits or Safe, dated 10/19/2019, indicated, A list of remote kit contents is posted on the outside of the kit and at other locations at each nursing station so that the information is readily accessible. The policy indicated, As soon as possible, the nurse records the medication used on the Remote Kit Inventory form kept inside or in the logbook kept in a designated location in the medication room. The policy indicated, The nurse is responsible for removing the doses from the kit, then reseals the kit with a yellow plastic enclosure (lock) and returns the kit to its designated secured location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to inform residents, their representatives, and families each time a confirmed infection of COVID-19 was identified. Specifically, the facility failed to inform residents, their representatives, and families by 5:00 PM the next calendar day following the occurrence of a confirmed infection of COVID-19 with information on mitigating action being implemented to prevent or reduce the risk of transmission. This had the potential to affect all the residents in the facility. Findings included: A review of the facility's line list for COVID-19 (a spreadsheet that tracks staff and residents that have tested positive for COVID-19) revealed the last person to test positive at the facility was Resident #307 on 11/02/2021. A review of Resident #307's laboratory report revealed the resident tested positive for COVID-19 on 11/01/2021 at the hospital. A review of the facility census revealed two current residents, Resident #35 and Resident #26, were in the facility when Resident #307 tested positive for COVID-19. A review of their electronic health records (EHR) revealed no documentation of the residents or resident representatives being notified of a positive COVID-19 case in the facility. An interview was conducted on 12/06/2021 at 12:57 PM with Resident #35, who had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #35 stated they were never told of a positive COVID-19 resident or staff member in the facility since they were admitted on [DATE]. An interview was conducted on 12/06/2021 at 12:59 PM with Resident #26, who had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Resident #26 stated they were never told of a positive COVID-19 resident or staff member in the facility since they were admitted on [DATE]. During an interview on 12/03/2021 at 1:45 PM, Assistant Director of Nursing C stated she was also the Infection Control Preventionist (ICP). ADON C stated the Administrator was the person responsible for notifying residents and families if there was a positive COVID-19 case in the facility. ADON C stated she thought it was done through email. During an interview on 12/06/2021 at 1:45 PM, the Director of Nursing (DON) stated whenever they had a positive test result for COVID-19, they notified the residents in person if they were cognitive, and if not, they called the resident's families. The DON stated it should be documented in a progress note. The DON stated the Administrator also sent out an email to the families, but that was not documented in the resident's record. During an interview on 12/07/2021 at 8:13 AM, the Administrator stated she sent out an email to all the families when the facility had a new positive COVID-19 test, and it was documented in the resident's record. The Administrator stated each manager was assigned residents to notify of new positive COVID-19 cases, and it was documented on the managers' audit sheets and not necessarily in the residents' records. These audit sheets were requested and not received by the end of the survey. The facility's policy and procedure on notifying residents and families of positive COVID-19 tests was requested from the DON on 12/04/2021 and was not received by the end of the survey.

Based on interview and record review, and facility policy review, the facility failed to implement a standardized menu with recipes and diet extensions that were reviewed by the facility's Registered Dietitian Nutritionist (RDN). This deficient practice had the potential to affect 61 residents who received meals from the facility kitchen. Findings included: A review of the facility's Menu Planning policy, dated 10/01/2018 and revised on 06/01/2019, revealed, A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences will be used. Menus will be prepared for each facility by their food vendor. The menus will be for a five-week cycle and will include a week at a glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide. The menus are reviewed and approved by the Consultant Dietitian. Intermittent changes must also be reviewed and approved by the Consultant Dietitian. The menu will be signed and dated by the Consultant Dietitian. During an interview on 12/01/2021 at 1:40 PM, the Certified Dietary Manager (CDM) stated they were not using a standardized menu. The CDM had been there for three weeks, and the kitchen had a three-week rotating menu that was created by the previous manager. There were no recipes or diet spreadsheets for kitchen staff to refer to when serving renal, diabetic, or heart healthy therapeutic diets. There were also no recipes or guidance for kitchen staff on appropriate serving sizes or how to prepare foods for the pureed or mechanical soft consistencies. The menu the kitchen was following was posted on the wall in the kitchen and was not available anywhere else. The kitchen staff had previous education on adequate serving sizes and what foods were appropriate for therapeutic diets. The CDM further stated the current menu they were serving had not been approved by a dietitian. During an interview on 12/01/2021 at 1:45 PM, the [NAME] stated they had no recipes or diet spreadsheets. The [NAME] stated they just cooked up what was listed on the posted menu and added in ingredients they thought went into each dish. During an interview on 12/01/2021 at 1:50 PM, the CDM stated when they first started three weeks earlier, the kitchen staff were just making different foods to serve the residents. The CDM recently found their food vendor's approved menus with spreadsheets and recipes in the computer and planned to implement that menu the following week. The CDM stated the Account Manager, who was an RDN, approved and signed off on the food vendor's menu cycle that day (12/01/2021). A review of the RDN Approval for Current Menu Cycle for the upcoming vendor's menu cycle to be implemented revealed, This current menu has been reviewed and approved for the Fall/Winter 2021/2022 menu cycle for all facilities, and was signed by the Account Manager on 12/01/2021. During an interview on 12/02/2021 at 1:35 PM, RDN OO stated Nutritionist Diet Technician, Registered (NDTR) NN oversaw food service from the kitchen. RDN OO did not go in the kitchen or monitor any part of food service such as the menus or serving of therapeutic diets. RDN OO did not approve the current three-week rotating menu and did not know who approved the menu. RDN OO stated it was important for the menus to be approved by an RDN, so the residents received the nutrients they needed to maintain their nutritional status. RDN OO further stated they did not know if the menu was sufficient to meet the needs of the residents; they would have to look at the menu to determine that. RDN OO thought the kitchen had recipes and diet spreadsheets but was not sure. RDN OO again stated they did not go into the kitchen and did not know if NDTR NN did any training with the kitchen staff. During an interview on 12/03/2021 at 1:00 PM, the Administrator stated the CDM had only been there for three weeks, and they were using a three-week rotating menu. The Administrator thought the previous director created the menu and trained staff to make the foods on the menu. The Administrator thought the kitchen had recipes and diet spreadsheets, so staff knew what to serve residents on therapeutic diets. The Administrator did not know if RDN OO knew the kitchen did not have recipes or diet spreadsheets or if RDN OO knew the menu had not been approved by a dietitian. RDN OO and NDTR NN were in the facility often and should have caught that the kitchen did not use recipes or had guidance on what to serve for therapeutic diets. The Administrator stated it was important to follow recipes and diet extensions because otherwise they did not know if what they were serving to residents was balanced or of the appropriate consistency. The Administrator further stated NDTR NN oversaw the kitchen, and RDN OO did not go into the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to conduct COVID-19 testing based on parameters set forth by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS). Specifically, the facility failed to test all residents and employees during an outbreak situation or according to the facility's county level of community transmission. This had the potential to affect all residents in the facility. Findings included: According to the Centers for Disease Control (CDC) Infection Control for Nursing Homes, last updated 09/10/2021, In nursing homes located in counties with substantial to high community transmission, unvaccinated health care professionals (HCP) should have a viral test twice a week. When responding to a newly identified COVID-19 infected HCP or resident, perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately and if negative, again five to seven days later. If additional cases are identified, testing should continue every three to seven days until there are no new cases for 14 days. According to the Centers for Medicare and Medicaid Services (CMS) in a QSO-20-38-NH memo, last updated 09/10/2021, staff testing of COVID-19 is based on the facility's county level of community transmission. Testing frequency of unvaccinated staff is as follows: -Low (blue) less than 5% = no testing recommended. -Moderate (yellow) 5.0% to 7.99% = once a week testing. -Substantial (orange) 8%-9.99% = twice a week testing. -High (red) greater than 10% = twice a week testing. A review of the facility's line list for COVID-19 (a spreadsheet that keeps track of staff and residents that have tested positive for COVID-19) revealed three residents and two staff members had tested positive for COVID-19 in September 2021, and three residents had tested positive for COVID-19 since 10/01/2021. Resident #306 tested positive for COVID-19 on 10/04/2021, and Resident #308 tested positive on 10/18/2021. The positive COVID-19 test for Resident #307 was on 11/02/2021. This kept the facility in outbreak status until 11/16/2021, requiring all residents and staff, regardless of vaccination status, to be tested every three to seven days, according to CDC guidelines. A review of the weekly COVID-19 tests results for the residents from 10/07/2021 through 11/23/2021 revealed the following: -On 10/07/2021, the resident in room [ROOM NUMBER] was not tested. -On 10/27/2021, the residents in rooms [ROOM NUMBERS] were not tested. -On 11/04/2021, the residents in rooms [ROOM NUMBERS] were not tested. -On 11/11/2021, the residents in Rooms 102 (second week in a row) and 107 were not tested. According to a daily COVID-19 report, dated 10/19/2021, the facility had 83 staff members. A review of the COVID-19 Staff Testing Logs from 10/03/2021 through 11/20/2021 revealed the following: -28 staff members were tested from 10/04/2021-10/09/2021, two were tested twice. -36 staff members were tested from 10/10/2021-10/16/2021, ten were tested twice. -29 staff members were tested from 10/17/2021-10/23/2021, three were tested twice. -15 staff members were tested from 10/24/2021-10/30/2021, three were tested twice. -27 staff members were tested from 10/31/2021-11/06/2021, six were tested twice. -25 staff members were tested from 11/07/2021 -11/13/2021, none were tested twice -21 staff members were tested from 11/14/2021-11/20/2021, two were tested twice. The facility was no longer in outbreak status as of 11/16/2021. A review of the facility's county transmission rate (obtained from https://covid.cdc.gov/covid-data-tracker ) from 11/16/2021 to 12/04/2021 indicated the county was at a substantial-to-high level. According to CDC guidelines, due to the county transmission rate, all unvaccinated staff should have been tested twice a week. A review of the COVID-19 Staff Testing Logs from 11/21/2021 through 11/27/2021 indicated 12 staff members were tested. None of the 12 staff members were tested twice that week. According to the staff summary of vaccination status, dated 11/30/2021, the facility had 100 staff members; 21 were not vaccinated and one had only one dose of the vaccine. A review of the COVID-19 Staff Testing Logs from 11/28/2021 through 12/04/2021 indicated seven staff members were tested. None of the seven staff members were tested twice that week. According to the staff summary of vaccination status, dated 12/03/2021, the facility had 99 employees. Twenty were not vaccinated, and one had only one dose of the vaccine. During an interview on 12/03/2021 at 1:45 PM, Assistant Director of Nursing (ADON) C stated she was also the Infection Control Preventionist (ICP). She stated she became certified in 2019. ADON C stated as of 11/20/2021, the facility was no longer in outbreak status, and since the county transmission rate for last week was less than 5% the unvaccinated staff and residents were tested for COVID-19 once a week. ADON C did not know what the county transmission rate was. ADON C stated she had been doing the testing for staff and residents up until approximately three to four weeks ago. ADON C stated the Assistant Administrator was not a nurse but was trained on how to properly perform the test, and she was the person who tested the residents and some of the staff. She stated other staff were tested by their managers. ADON C stated all the results went to the Administrator. During an interview on 12/06/2021 at 10:16 AM, ADON B stated he had been tested for COVID-19 twice weekly for several months, and it recently changed to weekly because the facility was no longer in outbreak status. During an interview on 12/06/2021 at 10:23 AM, ADON CC stated she was tested weekly for COVID-19. She stated she did recall being tested more than once in a week but could not remember when it was. During an interview on 12/06/2021 at 1:12 PM, Dietary Aide (DA) E stated the staff that were not vaccinated were being tested every two weeks for COVID-19. During an interview on 12/06/2021 at 1:32 PM, Certified Nurse Aide (CNA) MM stated she started working at the facility on 10/23/2021. She was unvaccinated and was tested for COVID-19 weekly. During an interview on 12/06/2021 at 1:53 PM, CNA P stated she was unvaccinated, and she was tested for COVID-19 weekly. During an interview on 12/06/2021 at 1:55 PM, Licensed Vocational Nurse (LVN) PP stated he was tested every week. During an interview on 12/06/2021 at 2:02 PM, Registered Nurse (RN) H stated she started working at the facility in September 2021 and had not been tested since she had been there. During an interview on 12/06/2021 at 1:45 PM, the Director of Nursing (DON) stated there was no specific person responsible for ensuring all staff and residents were tested weekly. She stated ADON C used to do all the testing, but now the Assistant Administrator usually tested the residents, but any nurse could do it. The DON stated it was documented on a form that was turned into the Administrator. The DON stated each department was responsible for testing their own staff. The DON stated the staff signed the testing log, and that was compared with the staffing for that day to ensure all staff were tested. She stated this was given to the Administrator and was sent to the corporate office. The DON stated she was not aware that all staff and residents were not being tested. During an interview on 12/07/2021 at 8:13 AM, the Administrator stated the facility tested all people in the facility during an outbreak. She stated each department did their own testing and gave her a report that she submitted to the state. She stated it was kept on one spreadsheet. This spreadsheet was requested and not provided by the end of the survey. An attempt was made on two different occasions to interview the Assistant Administrator, but they were unavailable. The facility provided procedures for how to perform a COVID-19 test but did not have any policies specific to who or when testing should occur. On 12/03/2021 at 1:45 PM, ADON C stated that they follow CDC and CMS guidelines.