Based on observation, interview, and record review, the facility failed to ensure all drugs and biological's were stored properly in the cart for 1 (100 hallway med aide cart) of 2 medication carts reviewed, in that: The facility failed to ensure Resident #5's Lyrica (pregabalin), a DEA controlled substance, was stored appropriately in a double locked container. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: During an observation of LVN B's medication cart for the 100 hallway on 5/15/2025 at 5:00 p.m., revealed one white capsule marked Z 14 and identified as Lyrica, a schedule V (5) controlled substance, was found in an unmarked medication cup that had been removed from the locked controlled substance box of the medication cart and left in the upper right drawer of the medication cart which did not have a separate locked compartment for controlled substances. During an interview on 5/15/2025 at 5:00 p.m., CNA B stated the white capsule marked Z 14 was a capsule of Lyrica meant for Resident #5. CNA B stated she accidentally popped the medication (removed it from it's original blister pack) earlier and did not want to throw it away. She stated when that happened , she normally just left the medication in a cup to the side. She stated the medication were not labeled. She declined to answer questions on how she was trained and what she should do in this scenario. During an interview on 5/16/2025 at 4:03 p.m., the DON stated her expectation of staff were if they popped medications and were unable to give it, for whatever reason, they should waste the medication . (discard). She stated in the case of Lyrica, since it was a controlled substance, the medication should be wasted with a witness and co-signed. The DON stated controlled substances should be stored in the locked narcotic drawer to prevent drug diversion. Record review of the DEA website at https://www.dea.gov, as viewed on 5/27/2025 revealed: The Controlled Substances ACT (CSA) placed all substances which were in some manner regulated under existing federal law into one of five schedules. This placement is based upon the substance's medical use, potential for abuse, and safety or dependence liability. Schedule V drugs have the lowest potential for abuse. Pregabalin was listed as a schedule V controlled substance. Record review of thefacility's policy, titled Controlled Medication Storage dated 01/23 revealed: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's medication at the correct time the medication was administered. This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being. The findings included: Record review of Resident #1's face sheet, dated 5/15/2025 revealed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses which included: displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (fracture to left leg bone with surgical repair), benign neoplasm of cerebral meninges (non-cancerous tumor of the lining of the brain and spinal cord) and generalized muscle weakness. Record review of Resident #1's 5-day admission MDS assessment dated [DATE] revealed a BIMS score of 4 which indicated a severe cognitive impairment. The assessment indicated the resident was dependent on staff for care and mobility. Record review of Resident #1's Care Plan dated 4/29/2025 revealed the resident had impaired cognitive function and staff should communicate with the resident/family/caregivers regarding resident's capabilities and needs. Record review of Resident #1's Order Summary for May 2025 revealed she had orders for: -gabapentin 100 mg, give one capsule by mouth three times a day for neuropathy. -cetirizine 10 mg, give one tablet by mouth in the morning for allergy symptoms. -metoprolol tartrate 12.5 mg by mouth two times a day for hypertension -benzonatate capsule 200 mg, give one capsule by mouth three times a day for cough. -ondansetron tablet 4 mg, give one tablet by mouth two times a day for nausea/vomiting. Record review of Resident #1's Medication Administration Audit Report dated 5/16/2025 revealed: -gabapentin 100 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m. by LVN A. -cetirizine 10 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A -metoprolol tartrate 12.5 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. -benzonatate 200 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. -ondansetron 4 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. -polyethylene glycol 17 grams was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. During an interview on 5/16/2025 at 4:26 p.m., Resident 1's family members stated they had concerns about the times Resident #1's gabapentin was administered. The family members stated they had asked an unknown staff member when the gabapentin was administered, and the staff member gave them times that seemed too close together. They stated they had not brought their concerns about gabapentin time administration with the administration. The family stated Resident #1 was no longer at the facility. During an interview on 5/16/2025 at 3:27 p.m., LVN A stated on 5/01/2025 she administered Resident #1's medication on time during the administration window. She stated on that day, the computer kept crashing and kicking her out. She stated she was keeping track of the medication administration on a piece of paper, which she stated, she later documented in the electronic medical record. LVN A stated she did not mark the correct time of the medication administration on the medical record. She stated she did not think about changing the entry time when she documented or marking it as a late entry. LVN A stated she was trained to mark medication administration at the time it was given. During an interview on 5/16/2025 at 4:03 p.m., the DON stated her expectation of staff was to notify the ADON on the floor and to notify her (DON) if they were having issues on the floor with the computer or medication administration. She stated the staff should let the management know if a time was documented incorrectly in the medical record so it could be corrected to ensure they know exactly when medication was administered. Record review of the facility's policy titled Medication Administration Schedule undated revealed the facility utilized liberalized med pass times with morning med pass occurring between 7:00 am-10:00 am. The policy did not address documentation. Record review of the facility's policy titled Medication Administration: General Guidelines dated January 2023 revealed: Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 2 elevators reviewed for essential equipment. The facility failed to ensure elevators #1 and #2 were functioning properly. This failure could place residents at risk of not having functional and safe mode of travel from floor to floor. The findings included: Record review of Elevator #1's Texas Department of Licensing and Regulation revealed last known annual inspection was 7/24/2024 and the hydraulic elevator passed inspection. Record review of Elevator #2's Texas Department of Licensing and Regulation revealed last known annual inspection was 7/24/2024 and the hydraulic elevator passed inspection. Record review of elevator service calls documented [elevator repair company portal] from 5/21/2024 to 5/15/2025 revealed a total of 25 service calls of which 4 were related service calls: -5/15/2025 3:54 pm (after surveyor intervention) elevator 1, Jumping very hard 1 of 2 with resolution documented as checked operation pit/cylinder/packing. -4/30/2025 customer says the elevator in service but it's still bouncing and traveling extremely slow 2 of 2 with resolution documented as checked operational care in-service. -12/13/2024 elevator 2, Bouncing, still in service with resolution documented as reset. -9/26/2024 stuck 1st floor, doors closed, keep on bouncing up and down-reoccurring issue with resolution documented as checked operation. During an observation on 5/15/2025 at 3:00 pm of elevator #2, while riding from the first floor to the second floor with an unknown staff member, the elevator bounced multiple times before coming to a stop on the intended floor. The unknown staff member patted the wall and said, Good old Betsy, and indicated that was normal for the elevator. During an observation on 5/15/2025 at 3:05 p.m., elevator #2 was noted with one minimal bounce upon decent when the elevator car approached the floor. On accent the elevator car bounced 9 times when ascending from floor 1 to 3. The elevator car descended from the 2nd to 3rd car with creaking, groaning, and popping heard but no bounce. On a second run elevator #2 bounced 12 times with very noticeable movement up and down as it approached the 2nd floor from the 1st floor. No inspection was posted in this elevator. During an observation on 5/15/2025 at 3:08 p.m., elevator #1 bounced 6 times when it approached the 2nd floor from the 1st floor and 5 times from the 2nd to 3rd floor. No inspection was posted in this elevator. During an observation on 5/16/2025 at 3:35 p.m. elevator #1 and elevator #2 were utilized to observe for bouncing and noises. Elevator #2 bounced 10-11 times before coming to a rest when going up. Elevator #1 bounced 5-7 times before coming to a rest when going up. No noises were heard during this test. The elevators were taken up and down several times to observe operation. During an interview on 5/15/2025 at 3:19 p.m., the Maintenance Director stated one of the shocks for the elevators was not working and it was a known issue for an unknown period of time. He stated he could not turn elevator #2 off as it would cause the other elevator to get hot. He stated elevator 2 had the worst bounce issue. He stated approximately two-weeks prior, the elevator company had been out to service the elevators. He stated they reset the elevators with their computers, and they were waiting for parts but the reset had not fixed the issue. The Maintenance Director stated he did have the annual inspections in an office and noted the inspections were due next month. He stated he did not document service calls or repairs and did not have any invoices for repairs or parts ordered. During an interview on 5/15/2025 at 3:24 p.m., the elevator repair company declined to give a history of maintenance or service calls/repairs on the elevators for the facility. They stated they would notify the account representative who would get in contact with the facility to provide the information. During an interview on 5/16/2025 at 1:22 p.m., the Maintenance Director stated he had reviewed the ticket history of the elevators. He stated the repair company come out and adjusted both elevators with their computer on 4/23/2025. He stated the adjustment fixed the issue. He stated later he noted the elevators were doing it again. He stated he did not notice the elevators bouncing as much until yesterday (5/15/2025) when the surveyor brought it to his attention. He stated he then notified the repair company again; they came back to the facility (after surveyor intervention) and had them open up the elevators to evaluate and noted that the packing on the elevators hydraulic system needed to be replaced. The Maintenance Director stated replacing the packing on a hydraulic elevator was a lot of work. He stated he was now waiting on a bid to fix the hydraulic lines. He stated the repair company looked at the hydraulics for both elevators but only one, elevator #2 needed to be replaced. He stated the issue was the elevators worked together and when there was an issue with one elevator it affected both. He stated he could not shut off one elevator because it would cause the second elevator to overheat. He stated when they overheat, they stop working. He stated they are too hot if their oil temperature is over 160-170 F. He stated he takes the temperatures of the returns to monitor. The Maintenance Director stated they always have issues with the elevators. He stated one employee with an unknown name notified him of the elevator bounce on an unknown date. He stated he must get approval before any elevator repairs can be authorized by Corporate. The Maintenance Director stated the elevators were needed to transport residents in and out of the facility. He stated he was not aware of any resident injuries related to the elevators. During an interview on 5/16/2025 at 3:51 p.m., the DON stated both elevators had been bouncing for a couple of months now. She stated the facility had people come out and look on it (unknown date). She stated the residents did utilize the elevators. She stated the risk of the bouncing was someone could fall. She stated they had not had that happen and there were no facility injuries from the elevators. Record review of the facility's policy titled Proper maintenance on Elevators last revised August 2022 revealed: If elevator is deemed inoperable by competent person elevator will be shut down and service ticket will be open with [elevator repair company]. The policy did not address car movement or bouncing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of four residents reviewed for physician orders for treatments. The facility failed to follow physician orders and obtain Resident #2's weight during night shift every Tuesday per physician order schedule. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #2's Care Plan, undated and accessed 03/13/2025, reflected the following focuses and interventions: - Focus: The resident has ADL self-care performance deficits and limitations in physical mobility. Activity Intolerance DX s/p ERCP, Dementia, date initiated 03/13/2025, with interventions, all initiated 03/13/2025 including: - -Eating: Supervision or touching assistance, - -Putting on/taking off footwear: Dependent, - -Chair/bed-to-chair transfer: Partial/moderate assistance, and - -Uses wheelchair. - Focus: Diet: Regular diet, pureed texture [sic] The resident has the potential for alterations in nutrition and hydration poor PO intake, cognitive deficits, date initiated 03/05/2025, with intervention Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change., date initiated 03/05/2025. Record review of Resident #2's Order Summary Report, dated as Active Orders as of: 03/13/2025, reflected: - Weights every night shift every Tue, order date 03/04/2025, start date 03/11/2025, and no end date. Record review of Resident #2's Treatment Administration Record, dated 03/01/2025 - 03/31/2025 and printed on 03/17/2025, reflected: - Weights every night shift every Tue, order date 03/04/2025 at 10:55 p.m., had a blank space, without an entry for Wt and a chart code and staff identifier at NOC 1 for 03/11/2025. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed the facility had residents with daily and weekly weights scheduled. She stated the residents in odd numbered rooms were scheduled to have their weights obtained by the night shift and the residents in even numbered rooms were scheduled to have their weights obtained by the day shift. She stated that if a weight was scheduled, it would pop up on the direct care nurse's and nurse aide's EMR. She stated that if a resident refused their weight to be taken, the staff should document that the resident refused. She stated that Resident #2 had a history of refusing a lot of things and it was likely that he refused his weight to be taken on Tuesday, 03/11/2025 and they should have tried to obtain it at a different time that day. She said that she wanted to say that the staff tried to obtain his weight three or four times, but she did not know if the staff documented that he refused. She stated the impact of the staff not obtaining his weight would be that his weight was not being tracked or monitored and then the staff would have no way of knowing if the resident had gained or lost weight over a course of time. She stated that the staff needed to document a refusal because it would show that they attempted to obtain a weight. During an interview on 03/14/2025 at 02:56 p.m., LPN I revealed she worked night shift, working from around 06:15 p.m. to 07:30 a.m. She revealed resident weights were obtained on Tuesdays for scheduled weekly weights. She stated that some residents are scheduled for weights during day shift and others on night shift. She stated she would often sit outside Resident #2's room and check on him every 10- 15 minutes during her night shift because he would often holler out at night and count out loud. She revealed that she did not recall if his weight was taken Tuesday night, 03/11/2025. She stated that if he had refused, the procedure was to document that he refused or that they were unable to obtain his weight. She stated if his weight was scheduled, it would have shown up on the Treatment Administration Record, but she did not remember if his did that night. She stated she worked Monday and Tuesday of that week, week of 03/11/2025. Record review of Resident #2's Weight Summary, undated and accessed on 03/17/2025, revealed Resident #2 was weighed on 03/14/2025 at 04:29 p.m. His weight history indicated a 7.4 pound or 4.4% weight loss in 9 days. Record review of Resident #2's progress note, titled *Health Status Note (nurses note), dated 03/14/2025 at 04:49 p.m., reflected Resident #2 was weighed. It noted Resident #2 was offered his supper tray, a shake, and an alternate meal and he refused. It noted Resident #2 stated he wanted to go back asleep. The note included that the dietitian was called and a new order for a dietary supplement was added to be given three times a day. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed scheduled weights were noted on the treatment sheet and on the EMR for the CNAs. She stated if a weight was not taken, the staff were to notify the managers and the managers would notify the doctor of the resident. She stated the resident's doctors typically wanted their residents weighed at least once a week and if the resident was refusing, the staff should document the refusal but try again to obtain the resident's weight for that week. She stated even if the weight was not taken on the scheduled day, the staff were to enter the weight on the day it was taken and ensure that the weekly weight was done. She stated that scheduled weights were to monitor for any significant changes. She stated Resident #2 was one of the residents that refused his weight to be taken on Tuesday, 03/11/2025. She stated staff tried to get him up again and he refused. She stated that the staff did eventually get his weight and she believed he had more shakes added to his orders. She stated that Resident #2 did not like to eat much, and his resident representative had reported he liked shakes. Record review of facility policy, Weight Policy, dated 11/2018, reflected, POLICY: 1. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. 2. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order .4. Residents will be weighed using the same scale [sic] at the same time of day and in the same way each time they are weighed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for one (Resident #2) of four residents reviewed for pressure ulcers. In three observations over three days, the facility failed to follow physician orders and apply Prevelon boots (cushioned boots, also known as heel protectors, designed to lift the heel off the bed and help prevent heel pressure injures and provide pressure relief) as ordered for Resident #2. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #2's Care Plan, undated and accessed 03/13/2025, reflected the following focuses and interventions: - Focus: The resident has ADL self-care performance deficits and limitations in physical mobility. Activity Intolerance DX s/p ERCP, Dementia, date initiated 03/13/2025, with interventions, all initiated 03/13/2025 including: - -Eating: Supervision or touching assistance, - -Putting on/taking off footwear: Dependent, - -Chair/bed-to-chair transfer: Partial/moderate assistance, and - -Uses wheelchair. - Focus: The resident has actual impairment to skin integrity r/t Pressure ulcer [sic] Left Heel ., date initiated 03/12/2025, with intervention Evaluate and treat per physician orders., date initiated 03/12/2025. Record review of Resident #2's Order Summary Report, dated as Active Orders as of: 03/13/2025, reflected: - Prevalon [sic] boots WHILE IN BED OR SITTING IN CHAIR every day and night shift, order date and start date 03/06/2025 with no end date. Record review of Resident #2's Treatment Administration Record, dated 03/01/2025 - 03/31/2025 and printed on 03/17/2025, reflected: - Prevalon [sic] boots WHILE IN BED OR SITTING IN CHAIR every day and night shift, order date and start date 03/06/2025 at 12:47 p.m., checked off at Day 0 time from 03/07/2025- 03/13/2025 and 03/15/2025 and at NOC 1 time from 03/06/2025- 03/08/2025 and 03/10/2025-03/16/2025. Day 0 for 03/14/2025 and 03/16/2025 were coded as 2, meaning Drug Refused per the chart code list. The space for NOC 1 on 03/09/2025 was blank, without a chart code and staff identifier. LPN A's initials were coded for the checked off dates 03/08/2025, 03/09/2025, and 03/13/2025 at Day 0 time. Record review of Resident #2's Initial Wound Evaluation & Management Summary document, dated 03/07/2025, reflected Resident #2 had a pressure wound on his left heel. It was sized 5.5 cm by 5.5 cm by not measurable with a surface area of 30.25 cm^2. It was staged as unstageable deep tissue injury with intact skin. It was noted to have been present on admission per staff report. Record review of Resident #2's Wound Evaluation & Management Summary document, dated 03/10/2025, reflected Resident #2 had a pressure wound on his left heel. It was sized 5.5 cm by 4.5 cm by not measurable with a surface area of 24.75 cm^2. It was staged as unstageable deep tissue injury with intact skin. The wound progress was noted to have improved as evidenced by decreased surface area. Record review of Resident #2's Wound Evaluation & Management Summary document, dated 03/17/2025, reflected Resident #2 had a pressure wound on his left heel. It was sized 5.0 cm by 3.8 cm by not measurable with a surface area of 19.00 cm^2. It was staged as unstageable deep tissue injury with intact skin. The wound progress was noted to have improved as evidenced by decreased surface area. During an observation on 03/13/2025 at 04:57 p.m., Resident #2 was observed lying in bed without Prevelon boots on his feet. During an observation on 03/14/2025 at 09:20 a.m., Resident #2 was observed sitting in a wheelchair next to the 2nd floor nursing station. He was observed to not have been wearing Prevelon boots. During an observation on 03/14/2025 at 11:37 a.m., Resident #2 was observed lying in bed without Prevelon boots on his feet. During an observation and interview on 03/17/2025 at 10:50 a.m., Resident #2 was observed lying in bed wearing Prevelon boots. Resident was observed asking LPN A to take the Prevelon boots off because they hurt. LPN A observed providing Resident #2 with education on their need to prevent further skin breakdown and encouraged him to allow her to keep them on him while he was in bed. He was observed to again ask for the Prevelon boots to be removed. Resident #2 stated when asked why he wanted the Prevelon boots off, I don't like them. During an interview on 03/17/2025 at 10:50 a.m., LPN A revealed today, 03/17/2025 was the first day Resident #2 received his Prevelon boots. She stated they were ordered previously, and they were waiting for them to arrive. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed the facility had Prevelon boots in stock and there should not have been a delay in providing them to a resident. She stated Resident #2 does have a history of removing things and she was not made aware of the staff not having his Prevelon boots. She stated she did not know why Resident #2 did not have the Prevelon boots on. She stated the impact of him not having the boots on would depend on if he had any pressure points on his feet and if he did, it could cause pressure ulcers. Record review of facility policy, Foot Care, dated 07/2024, reflected, POLICY: This facility will ensure that all residents receive proper treatment and care to maintain mobility and good foot health by providing foot care and treatment in accordance with professional standards or practice including prevention of complications from a resident's medical condition including but not limited to: . and immobility affecting foot condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for 14 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15) of 14 residents and involving one (LPN A) of six staff observed for confidentiality of records. The facility failed to ensure LPN A would not leave a Vital Signs Flow Sheet Report on a 200-East Hall medication cart exposing 200-East Hall residents' personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: During an observation on 200-East Hall on 03/13/2025 at 09:18 a.m., revealed an unattended and visible Vital Signs Floor Sheet Report, dated 03/13/2025 for shift 6A-6P (06:00 a.m. to 06:00 p.m.). The staff identified on the document was LPN A, CNA B for 06:00 a.m. to 12:00 p.m., and CNA C for 12:00 p.m. to 06:00 p.m. The document was observed facing up on an unattended, locked medication cart half-way down 200-East Hall. The document displayed 14 resident's names with their assigned room numbers (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15 residing in rooms from 201 to 215) and included information such as: blood pressures, pulses, respirations, oxygen saturations, temperatures, if continent or incontinent, and identified two residents on dialysis with their appointment time. Resident #2 and Resident #8, were listed on the report. Staff, residents, and facility guests were not observed standing or walking down the 200-East hall near the medication cart the time of observation. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed medication aides were responsible for taking the residents' vital signs. She stated the medication aides would give her a copy of their vital signs document and keep a second copy for their use when they enter the information into the computer. She stated the vital signs document should not be in view of everyone. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed her expectation was that no personal protected information would be visible to anyone passing by on the facility halls. She stated that personal protected information was each resident's personal information and other people should not have access to their information. During an interview on 03/17/2025 at 10:07 a.m., ACNO E revealed she asked the facility staff to carry a blank sheet to put over their vitals report or to carry the report in their pocket. She revealed a vital report having been visible would be a HIPAA violation. Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's progress note, titled CSC- BIMS Evaluation, dated 03/05/2025 at 11:01 a.m., reflected Resident #2 had a BIMS score of 4.0, which indicated he was severely cognitively impaired. During an interview on 03/17/2025 at 10:50 a.m., Resident #2 stated, I don't know what that is when asked how he felt about his blood pressure, pulse, and room number being visible on a document on the facility hall. Record review of Resident #8's admission Record, dated 03/17/2025, reflected a [AGE] year-old female. She was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's admission MDS, signed as completed on 03/10/2025 by the RN Assessment Coordinator, reflected Resident #8 had a BIMS score of 14.0, which indicated she was cognitively intact. During an interview on 03/17/2025 at 11:02 a.m., Resident #8 stated, I don't like everyone to know my information when asked how she felt about her blood pressure, pulse, and room number being visible on a document on the facility hall. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed she expected staff to keep the vitals report in binders. She revealed a vital report included patient health information that should remain confidential. Record review of facility policy, Medical Records, dated as last revised 05/2023, reflected, Purpose: To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meet the requirements set forth in Federal and State laws and regulations, and to define the portion of an individual's healthcare information, whether in paper or electronic format, that comprises the medical/dental record. Under Procedure, the policy included Ensuring the privacy of protected health information (PHI) by logging out of laptops when not in use or keeping paperwork concealed and Each resident's protected health record will be filed, stored, restricted from public access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care within 48 hours of a resident's admission for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission that addressed the services that were being provided for Resident #1, Resident #2, and Resident #3. This failure could place newly admitted residents at risk for not receiving the care, services, and continuity of care to meet their needs. Findings included: Record review of Resident #1's admission Record, dated 03/13/2025, reflected a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 03/10/2025 to an acute care hospital. Record review of Resident #1's Medical Diagnosis EMR tab, undated and accessed on 03/12/2025, reflected Resident #1 had diagnoses which included syncope (fainting) and collapse, unspecified fall, and hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body). Record review of Resident #1's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 03/03/2025 at 03:13 p.m., reflected Resident #1 had severely impaired vision, was dependent on device for mobility, independent for fluid intake during meals, incontinent of bowel and bladder, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could not bear weight through at least one lower extremity. Record review of Resident #1's Initial/Baseline Care Plan, dated and locked 03/04/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #1's admission MDS, signed as completed on 03/12/2025 by the RN Assessment Coordinator, reflected Resident #1 had a BIMS score of 06, which indicated she was moderately cognitively impaired. She was documented as needed some help for self-care with requiring supervision or touching assistance for eating and oral hygiene, substantial/maximal assistance with toileting hygiene and lower body dressing, partial/moderate assistance with walking 10 feet, and dependent for walking 50 feet with two turns and 150 feet. She was documented as occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #1's Care Plan, undated and accessed on 03/14/2025, reflected all care planned focuses, goals, and interventions initiated on 03/12/2025. Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Record review of Resident #2's Nurse-to-Nurse Report Sheet, dated 03/04/2025 at 09:53 p.m. by LPN F, reflected LPN F received report on Resident #2 by a hospital nurse prior to his transfer to the facility. The report included under Weight bearing Status, Resident #2 was bedbound and required two-person assist for all care needs. Incontinent of Urine and Stool were both noted to be highlighted on the report sheet. Record review of Resident #2's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 03/05/2025 at 09:50 a.m., reflected Resident #2 was bed bound, required extensive physical assistance for fluids, incontinent of bowel and bladder, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could not bear weight through at least one lower extremity and have good trunk control. Record review of Resident #2's Initial/Baseline Care Plan, dated and locked 03/05/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #3's admission Record, dated 03/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #3's Medical Diagnosis EMR tab, undated and accessed on 03/17/2025, reflected Resident #3 had diagnoses which included encounter for other orthopedic aftercare (care provided after a corrective or preventative treatment on deformities, disorders, or injuries of the bones or muscles), spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord), and muscle wasting and atrophy (a shrinking of muscle or nerve tissue). Record review of Resident #3's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 02/25/2025 at 05:50 p.m., reflected Resident #3 had no nutritional risks, was dependent on device for mobility, continent of bowel and bladder, had a condom catheter, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could bear weight through at least one lower extremity and have good trunk control. Record review of Resident #3's Initial /Baseline Care Plan, dated and locked 02/26/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #3's admission MDS, signed as completed on 03/03/2025 by the RN Assessment Coordinator, reflected Resident #3 had a BIMS score of 10, which indicated he was mildly cognitively impaired. He was documented as having upper extremity impairment on both sides, had used a walker and wheelchair in the last 7 days, needed supervision or touching assistance for eating and oral hygiene, substantial/maximal assistance with toileting hygiene and lower body dressing, and dependent for walking all distances. He was documented as occasionally incontinent of urine and bowel. Record review of Resident #3's Care Plan, undated and accessed on 03/14/2025, reflected the following focuses and interventions: - Focus: The resident has impaired visual function., date initiated 02/26/2025 with Intervention: Keep call light and other key items within reach., date initiated 02/26/2025. - Focus: The resident has difficulty hearing at times., date initiated 02/26/2025 with Intervention: Face guest when speaking to them., date initiated 02/26/2025. - Focus: The resident is incontinent., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - BRIEF USE: the resident uses disposable briefs. Change as needed, - Clean peri-area with each incontinence episode., - INCONTINENT: Check every 2-3 and as needed for incontinence. Wash, rinse and dry perineum (area of skin between the genitals and the anus). Change clothing PRN after incontinence episodes., and - SKIN: Provide skin care with each incontinent episode. - Focus: The resident is at risk for falls., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - Anticipate and meet the resident's needs., - Ensure bed brakes are locked, and - Review information on past falls and attempt to determine cause of falls . - Focus: The resident has had an actual fall on 2/25/25 r/t Poor Balance, was assisted and witnessed by staff, date initiated 02/27/2025 with Interventions initiated on 02/27/2025 including: - Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to al requests for assistance. and - PT consult for strength and mobility. - Focus: The resident has bowel incontinence., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - Check resident every two hours and assist with toileting as needed, - Provide pericare after each incontinent episode, - Provide resident with adequate time to eliminate to minimize incontinent episodes, and - SKIN: Provide skin care with each incontinent episode. The Care Plan did not include an additional focus or interventions for ADL transfer and mobility needs. During an interview on 03/13/2025 at 05:33 p.m., RN G stated the baseline care plan was based off the initial nursing assessment with input from the dietary and therapy department. He stated the ADLs are first and must absolutely be part of the baseline care plan. He stated the initial nursing assessment was done by the direct care nurse, but they did not complete the baseline care plan. He stated he believed it was the admission nurse's duty to complete the baseline care plan. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed the direct care nurses did not complete the admissions documents for new residents. She stated the direct care nurses would receive a nurse-to-nurse document and usually a verbal report from the admissions nurse regarding new resident's ADL needs. During an interview on 03/13/2025 at 05:55 p.m., RN H stated the baseline care plan was completed by the admissions nurse. During an interview on 03/14/2025 at 01:49 p.m., CNA B revealed for new residents she would not receive a report on the new resident's ADL needs from a nurse or be provided any documentation. She stated that the nurse would receive a report, but she would typically have to ask the resident directly and learn about the resident's needs through observation. She stated if she did receive any type of report, it would come from the CNA leaving from the prior shift; however, she stated that the prior shift CNA would typically be gone or leaving at the time of her arrival for her shift, and they would not do a shift-to-shift report. During an interview on 03/14/2025 at 02:56 p.m., LPN I revealed for new residents, the direct care nurses would receive a nurse-to-nurse document and then provide a verbal report to the next nurse coming on shift. She stated oncoming nurses would also have the nursing assessment reports, which would include documentation on the resident's needs. During an interview on 03/14/2025 at 04:06 p.m., the DOR revealed the facility had therapy staff present seven days a week and new resident evaluations were generally done on the same day of admission, but always completed 24-48 hours from admission. She stated for initial communication of resident ADL needs, the nurses would receive a nurse-to-nurse report; however, once the therapy department assessed the resident, the therapy department would typically provide a verbal report to the direct care nursing staff of the resident's safe transfer needs and any restrictions. She stated the direct care staff had access to the therapy evaluations in the EMR for review. During an interview on 03/14/2025 at 04:37 p.m., LPN J revealed for new residents, she would know the resident's needs from the communication from the transferring hospital and through observing the resident. She stated some residents would be admitted with orders for feeding assistance and the nurse-to-nurse report may include a meal texture recommendation. She stated she could not recall any evaluations or documents available that showed a new resident's ADL needs, only the daily nurse notes on their observations of the resident during their shift. During an interview on 03/14/2025 at 05:11 p.m., LPN F revealed for her part of the baseline care plan, she would receive a detailed report from the transferring hospital for continuation of care and upload the nurse-to-nurse report to the new resident's chart. She stated following that step, the direct care nurse would initiate a nurse admission assessment and one of the facility RNs, typically the CNO or RN E would open a baseline care plan. She stated that once she completed the nurse-to-nurse report and the medication reconciliation and the direct-care nurse completed the head-to-toe assessment, the RN would initiate the care plan with the information from those documents and may ask clarifying questions if needed. She stated she would give a physical copy of the nurse-to-nurse report to the direct care staff. She stated that if direct care staff did not have consistent knowledge of a resident's ADL needs, it would impact the resident greatly because their care would be inconsistent. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed baseline care plans were done within 72 hours of admission. She stated that the baseline care plan needed to be initiated by herself or a facility RN. She stated that she would try to go through the baseline care plans to make sure they were as accurate as possible, including capturing any changes in the resident's care. She revealed the baseline care plan would have any information that the facility had captured for the resident, including generally having the initial therapy evaluations. She stated it might include if the resident required a Hoyer transfer, needed feeding assistance, or the resident's ability to walk. She stated the baseline care plan would include whatever information the facility knew about the resident. She stated ADL needs were communicated to direct-care staff verbally, on the nurse-to-nurse report sheet, and during CNA-to-CNA walking rounds. She stated the CNAs going off shift were supposed to do a verbal report and walking round with the CNAs coming on shift prior to leaving. She stated that if there were any changes in the resident's status or needs, the ACNO would let their staff know. She revealed that if the direct care staff's knowledge of a resident's needs were inconsistent, it could cause harm. Record review of facility policy, Care Plan, dated as last revised 04/2024, reflected, POLICY: 1. A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission, to the facility. This care plan includes minimum health care information necessary to properly care for the resident. 2. Required Components of the Baseline Care Plan a. Initial goals based on admission orders i. Services planned to attain or maintain resident's highest practical physical, mental, and psychosocial well-being including but not limited to: ADLs, Nutrition, Fall Risk, Skin Integrity and Pain Management b. Dietary Orders c. Therapy services .

Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for three (Cart 200-East Hall, Cart 200-West Hall, and Cart 300-West Hall) of six reviewed for drug storage. The facility failed to ensure medication carts, 200-East Hall and 200-West Hall on the second floor and 300-West Hall on the third floor were secured when unattended on 03/12/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation and interview on 03/12/2025 at 03:07 p.m., a medication cart on 200-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:08 p.m., RN G was observed coming out of a resident room. RN G confirmed the medication cart was his and that the cart was unlocked. He stated he had just gone to quickly administer a Tylenol to one of his residents. He stated the medication drawers that were accessible included medications such as over the counter medications, stool softeners, insulin with insulin needles, thyroid medications, and lovenox injections (a blood thinner used to prevent and treat blood clotting). RN G stated the residents on his hall required assistance with ambulation and were not independently mobile. During an observation and interview on 03/13/2025 at 03:15 p.m., a medication cart on 300-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:18 p.m., RN H was observed coming out of a resident room. RN H initially stated the medication was locked, then confirmed it was unlocked after checking. She stated her narcotics drawer was double locked and was never unsecured. She stated supplies that were accessible when the cart was unlocked included diabetic supplies, cleaning wipes, saline, oxygen supplies, prescription creams, Lidoderm patches (a numbing medication on an adhesive patch used to relieve pain), prescription medications, and breathing treatments, including albuterol (used to relax the muscles in the airway and increase air flow to the lungs). She stated she had quickly gone to one of her resident's rooms to assist him to use the restroom and empty his urinal. She stated she was only gone about two minutes. She stated all of the patients on her hall required assistance with mobility and were encouraged to use them call lights and not attempt ambulate on their own. During an observation and interview on 03/13/2025 at 05:47 p.m., a medication cart on 200-East Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 05:48 p.m., LPN A identified the medication cart as hers. She stated she was checking resident blood sugar values and was only around the corner of the hall for a short time. She stated her residents required a lot of assistance and all required assistance with ambulation. She stated the medications in the cart were for the residents on the 200-East Hall but did not give detail of the medications that were accessible when the cart was unlocked. She did state that the narcotics were still locked with a separate lock. During an interview on 03/13/2025 at 05:33 p.m., RN G revealed that an unlocked cart would be a concern for patients because they could have possibly taken something from the cart. He stated the impact of this would depend on the type of medication taken. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed medication and treatment carts needed to be locked. She revealed the concern would be that anyone could have had access to the items in the cart and could walk away with them. During an interview on 03/13/2025 at 05:55 p.m., RN H revealed the concern for an unlocked medication cart was that someone could get into the cart and take something that they should not have access to and that does not belong to them. She stated that this could cause medical problems, including someone could get hurt. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed her expectation for staff was that if they were not there and present in front of their medication carts, they were to lock it. She stated the impact of an unlocked medication cart was that someone could get into the cart and get into something that they shouldn't. That this could cause harm. She stated the impact would depend on what the person got into, the carts had injectables and medications, so the impact could range from nothing to anything. During an interview on 03/17/2025 at 10:07 a.m., ACNO E revealed her expectation was for medication carts to be always locked. She stated the impact of an unlocked medication cart was that one of the confused residents wandering around may get ahold of anything. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed her expectation was for medication carts to be always locked. She stated that the importance of securing carts was to make sure that no one goes into the cart and ingests something that they shouldn't. Record review of facility policy, 4.1 Storage of Medication, dated as copyrighted 2007 from the Nursing Care Center Pharmacy Policy & Procedure Manual, reflected, POLICY Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, for 1 of 30 residents (Resident #79) reviewed for call light accessibility and functionality, in that: On 07/09/2024 at 01:00 PM Resident #79 utilized his call light which did not illuminate the nurse call light directly outside of and above of his room door. This failure could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions and or is out of reach. The findings included: A record review of Resident #79's admission record dated 08/15/2024 revealed an admission date of 7/15/24 with diagnoses which included acute kidney failure (the kidney was not functioning correctly), type 2 diabetes mellitus (a condition in which the body's blood sugar is not controlled), and primary hypertension (a condition in which the force of blood against the artery walls is too high). A record review of Resident #79's 5-day Medicare MDS assessment dated [DATE] revealed Resident #79 with a BIMS of 10 (indicating moderate cognitive impairment) A record review of Resident #79's care plan dated 7/18/24 revealed, Resident #79 had care needs of decreased vision, hard of hearing, and fall risk. During an observation and interview on 08/12/24 at 11:00am resident #79 stated that his bathroom call light was not working and he was not sure how long it had been inoperable. Resident #79 stated that he worried about the call light in the bathroom not working as he had recently fallen in his room. Observation revealed the bathroom call light cord when pulled did not activate the room's call light to alert the nurses station. During an interview on 08/12/24 with LVN-D at 11:05am she stated that she had just started working on the resident hallway and was not aware that Resident 79's bathroom call light was not working. During an interview on 08/12/2024 at 11:10 am the maintenance director stated he was not aware the call light for Resident #79's room was not working and had not received a work order request to fix it. The Maintenance Director upon further observation confirmed that the wiring for the bathroom call light had become disconnected from the room's call light device making it inoperable. The Maintenance Director completed the repair of the call light device. He stated that having the call light device working properly was important for resident needs to be met and in the case of an emergency. A record review of the facility's policy on Preventative Maintenance dated 05/24 stated that preventative maintenance is to be completed in accordance with all state and federal requirements. A record review of the facility's policy on Call Light Outage date 04/23 stated that should a staff member find a call light not to be working, they will immediately notify maintenance to replace the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to deliver the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being for 3 of 30 Residents (Resident # 201, Resident # 67, and Resident # 203 who were reviewed for call light response in that: The facility failed to deliver timely call light response for Resident #201, Resident # 67, and Resident # 203. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: Record review of Resident #201's face sheet dated 8/15/24 revealed Resident # 201 was admitted on [DATE] with diagnoses of fusion of spine (a surgical procedure to correct problems with the spine, type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar), and adult T-cell lymphoma (a cancer of the immune system). Record review of Resident # 201's admission MDS assessment dated [DATE] revealed that Resident # 201's BIMS score was not documented. Record review of Resident # 201's care plan initiated on 8/13/24 revealed Resident # 201 was at risk for falls and incontinence. Record review of Resident #67's face sheet dated 8/15/24 revealed Resident #67 was admitted on [DATE] with diagnoses of pulmonary embolism (a condition in which there is a blood clot in the lungs), acute respiratory failure (a condition in which the lungs are not operating properly, and severe protein-calorie malnutrition (a condition in which the body does not receive enough protein over a period of time) Record review of Resident # 67's 5-day MDS assessment dated [DATE] revealed a BIMS score of 13 (which indicates the cognition is intact). Record review of Resident # 67's care plan initiated on 8/1/24 revealed Resident# 67 was at risk for falls and incontinence. Record review of Resident # 203's face sheet dated 8/15/24 revealed Resident # 203 was admitted on [DATE] with diagnoses of anemia (a condition in which the body does not have enough healthy red blood cells), UTI ( a condition in which there was an infection in the body's urinary track), and malignant neoplasm of the endocervix( a condition in which there is cancer in the endocervix). Record review of Resident # 203's 5-day MDS assessment dated [DATE] revealed a BIMS score of 13 (which indicates the cognition is intact). Record review of Resident #203's care plan initiated on 8/2/24 revealed Resident #201 was aat risk for falls and incontinence. During an interview on 8/12/24 at 2:00pm with Resident 201 he stated that in the morning on 8/12/24 he put his call light on when he was feeling nauseous and then he had vomited Resident # 201 stated that it took staff 2 hours to respond to his call light and to clean the emesis in his room. Resident #201 stated that waiting for the staff to respond to his call light and clean the emesis in his room was very upsetting and he was considering self-discharge from the facility. During an interview on 8/12/24 at 2:35pm with OT-E she stated that Resident #201 had spoken with her about his frustration with the call light response for his feeling of nauseous and then having vomited. During an interview on 8/12/24 at 3:00pm with CM-F she stated that Resident #201 had spoken with her about his frustration with the call light response for his feeling on nauseous and then having vomited. During an interview on 8/12/24 at 2:20pm with Resident #67 she stated she had an experience with her room call light within the last several days in which she put her light on in the morning for a toileting need and staff did not respond to her call light until after lunch. During a phone interview on 8/14/24 at 10:00am with a family member of Resident # 67, she stated that she visits Resident #67 often and has observed that it took staff over one hour on several occasions to respond to the room call light. The family member stated that the call light response time was very upsetting. During a group interview on 8/13/24 at 2:00pm Resident 203 stated that since her admission to the facility there have been several occasions in which it took staff 45 minutes to respond to her call light. Resident #203 stated that she felt very frustrated that she had to wait so long for her call light to be answered. Record review of the facility's resident council meeting notes for 7/25/24 revealed that a Resident who was discharged had felt that her call light response needed improvement. Record review of the facility's grievance log revealed a resident grievance dated 8/7/24 in which a Resident who was discharged had felt that staff did not respond well to her call lights. During an interview on 8/15/24 at 10:15am with the DON she stated that her expectation is for staff to respond promptly to resident call lights. During an interview on 8/15/24 at 10:40am with the Administrator, she stated that she reviewed resident council notes and grievances and felt that staff response to resident call lights was done in a timely manner and that there was not a problem in this area. Record review of the facility's admission Agreement that was undated stated under the Statement of Resident Rights the following: ' The right to live in an environment that promotes and supports each resident's dignity and to be treated with consideration and respect.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 8 of 25 residents (Residents #77, #99, #100, #102, #106, #149, #150, and #199) that were reviewed for baseline care plans in that: The facility failed to complete (Residents #77, #99, #100, #102, #106, #149, #150, and #199) baseline care plans within 48 hours. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: Record review of Resident #77's face sheet, dated 08/15/2024, revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included: acute and chronic respiratory failure with hypoxia, COVID19, pneumonia due to SARS-associated coronavirus, chronic obstructive pulmonary disease, unspecified, acute bronchitis, pulmonary hypertension, unspecified, hypothyroidism, unspecified, depression, unspecified, hypertension, unspecified atrial fibrillation, muscle wasting and atrophy, not elsewhere classified, multiple sites, and scoliosis. Record review of Resident #77's 5-day MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #77's Initial/Baseline Care Plan showed a completion date of 07/29/2024 with a locked date of 07/29/2024. Record review of Resident #99's face sheet, dated 8/14/2024, revealed Resident #99 was admitted to the facility on [DATE] with diagnoses which included: Sepsis-unspecified organism, Bacteremia, MSRA infection-unspecified site, acute pulmonary edema, anemia in chronic kidney disease, hypothyroidism, essential (primary) hypertension, end stage renal disease, repeated falls, and dependence on renal dialysis. Record review of Resident #99's 5-Day MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #99's Initial/Baseline Care Plan showed an initiation date of 08/12/2024 and completion of 08/14/2024. Record review of Resident #100's face sheet, dated 08/15/2024, revealed Resident #100 was admitted to the facility on [DATE], with diagnoses which included: Displaced comminuted fracture (broken bone that has at least two breaks) of right patella (kneecap)-subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, pain due to internal orthopedic prosthetic devices, implants, grafts, subsequent encounter, psoriatic arthritis mutilans (a severe form of arthritis that causes severe damage to joints), depression - unspecified, essential tremor, essential (primary)hypertension (high blood pressure), and unspecified asthma (condition in which airways narrow and swell and may produce mucus). Record review of Resident #100's 5-Day MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #100's Initial/Baseline Care Plan showed an initiation and completion date of 08/14/2024. Record review of Resident #102's face sheet, dated 08/15/2024, revealed Resident #102 was admitted to the facility on [DATE] with diagnoses which included: Encounter for surgical aftercare following surgery on the genitourinary system, acquired absence of kidney, chronic obstructive pulmonary disease (lung disease that blocks airlfow making it difficult to breathe)-unspecified, depression-unspecified, peripheral vascular disease - unspecified, spinal stenosis (narrowing of spine) - site unspecified, hyperlipidemia (high levels of fat particles in blood) - unspecified, and essential (primary) hypertension (high blood pressure). Record review of Resident #102's 5-Day MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated intact cognitive response. Record review of Resident #102's Initial/Baseline Care Plan showed an initiation and completion date of 8/13/2024. Record review of Resident #106's face sheet, dated 8 /15/2024, revealed Resident #106 was admitted to the facility on [DATE] with diagnoses which included: Fournier Gangrene, acute and subacute infective endocarditis, MRSA infection as the cause of diseases classified elsewhere, severe sepsis with septic shock, Type2 Diabetes Mellitus with hyperglycemia, anemia - unspecified, major depressive disorder - single episode unspecified, epilepsy - not intractable without status epilepticus, essential (primary) hypertension, cardiomyopathy-unspecified, cerebral ischemia, atherosclerotic hear disease of native coronary artery without angina pectoris, and paroxysmal atrial fibrillation. Record review of Resident # 106's 5-day MDS assessment dated [DATE] revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #106's Initial/Baseline Care Plan showed a completion date of 8/14/2024. Record review of Resident #149's face sheet, dated 08/15/2024, revealed Resident #149 was admitted to the facility on [DATE] with diagnoses which included: encounter for surgical aftercare following surgery on the circulatory system, atherosclerosis of native arteries of extremities with intermittent claudication, left leg, pain due to vascular prosthetic devices, implants and grafts, subsequent encounter, unspecified chronic bronchitis, type 2 diabetes mellitus with hyperglycemia, bipolar disorder, current episode mixed, moderate, hyperlipidemia, depression, essential (primary) hypertension, chronic kidney disease, stage 3 unspecified, and post-traumatic stress disorder, chronic. Record review of Resident #149's admission MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated intact cognition. Record review of Resident #149's Initial/Baseline Care Plan showed a completion date of 08/08/2024 with a locked date of 08/08/2024. Record review of Resident #150's face sheet, dated 08/15/224, revealed Resident #150 was admitted to the facility on [DATE] with diagnoses which included: muscle wasting and atrophy, not elsewhere classified, multiple sites, depression, epilepsy, unspecified, not intractable, without status epilepticus, insomnia, hereditary and idiopathic neuropathy, unspecified, dysphagia following cerebral infarction, peripheral vascular disease, unspecified, personal history of traumatic brain injury, presence of neurostimulator, presence of cerebrospinal fluid drainage device, and hypothyroidism, unspecified. Record review of Resident #150's 5-day MDS assessment dated [DATE], revealed a BIMS score of 99, which indicated unable to participate with BIMS. Record review of Resident #150's Initial/Baseline Care Plan showed a completion date of 08/13/2024 with a locked date of 08/13/2024. Record review of Resident #199's face sheet dated 08/14/24 with recent admission date of 8/7/24 and diagnoses which included: displaced fracture of the left tibia (a left broken shinbone), sepsis (an infection in the blood), and malignant neoplasm of the breast (breast cancer) Record review of Resident #199's 5-day Medicare MDS, completed on 8/14/24, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #199's Baseline Care Plan shows an initiation and completion date of 8/13/24. During an interview with LVN-MDS-C on 08/14/24 at 2:25 p.m., she confirmed that the baseline care plan for Resident # 199 was not done within the required time frame of 48 hours after admission. The MDS Coordinator stated that having the baseline care plan completed within the required time frame was important for resident needs to be met. During an interview with the DON on 8/14/24 at 3:00 p.m., she stated that the time frame for completion of the baseline care plan for Resident # 199 was not met. The DON stated that having the baseline care plan completed within 48 hours of the admission date would help ensure that the resident needs were met. During an interview on 08/15/2024 @ 10:01a.m., the DON stated the initial/baseline care plans for Residents #99, #100, #102 and #106 were not completed within the required time frame of 48 hours. The DON further stated she was responsible for the completion of the initial/baseline care plans, and with her other job duties, she just couldn't get it all done in time. The DON stated the care plans are important to identify and help ensure residents' needs are met. During an interview on 08/15/2024 at 1:55 p.m. the DON stated regarding the initial/baseline care plans for Resident #77, Resident #149 and Resident #150 she was not sure what had happened, and they were missed. The DON further stated she was responsible for the completion of the initial/baseline care plans, and they are supposed to be done within 48 hours from the admission of the patient. The DON stated the care plans important for the nurses, so they knew how to take care of the patients. Review of the facility policy and procedure titled, Care Plans, revision/reviewed dates November 2018, 11/2019, 11/2020, 09/2021, 10/2022, 04/2023, revealed, Policy: A baseline care plan is developed for each resident upon admission, but not later than 48 hours of admission, to the facility. This care plan includes minimum healthcare information necessary to properly care of the resident.

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 and to help prevent the development and transmission of communicable diseases and infection for 2 of 11 residents (Residents #89 and #204) reviewed for infection control and for residents who eat in their rooms in halls, in that: 1. RN-E did not sanitize glucometer in between uses with Residents #204 and #89, or after leaving Resident's #89 room, who was on droplet precautions. 2. RN-E failed to wash or sanitize his hands between glove changes before administering medications to Resident #204 and Resident #89. RN-E failed to wash or sanitize his hands when entering or exiting Resident #89's room, who was on droplet precautions. 3. Server B during meal pass did not sanitize hands between trays when entering and exiting resident rooms. These deficient practices could place residents at risk for infection due to improper care practices. The findings include: 1. Record review of Resident's #204's face sheet, dated 08/15/2024 revealed an admission date of 08/12/24 with diagnoses which included: Endocarditis (infection of heart valve), valve unspecified; bacteremia (bacterial infection of blood); Type 2 Diabetes Mellitus (problem in way body regulates and uses sugar (glucose) as fuel) and Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone). Record review of Resident #204's physician orders dated 08/15/2024 revealed an order for HumaLOG Solution 100 UNIT/ML (Insulin Lispro (Human)) inject per sliding scale . Record review of Resident #89's face sheet dated 08/15/2024 revealed an admission date of 07/25/2024 with diagnoses which included: Arthritis due to other bacteria, right knee (Joint inflammation); acute kidney failure (condition in which the kidneys can't filter waste from the blood); sepsis (serious condition in which the body responds improperly to an infection); morbid obesity (a disorder involving having too much body fat which increases risk of health problems), hypothyroidism-unspecified (condition in which the thyroid gland doesn't produce enough thyroid hormone), and essential (primary) hypertension (high blood pressure). Record review of Resident #89's physician orders dated 08/14/2024 revealed an order for Diabetic: accucheck before meals and at bedtime and Strict one room droplet isolation with all services provided in room alone. Record review of Resident #89's Care Plan dated 07/29/2024 revealed Focus- Covid Positive Date initiated: 08/14/2024 and under interventions for the Focus area: Dedicated equipment will be used whenever possible. When not, thoroughly disinfect equipment between residents, using EPA-registered disinfectant for Use Against SAR-CoV-2. Observation on 08/14/2024 between 12:09pm and 12:19pm revealed RN-E checked the blood glucose reading of Resident #204 and then without sanitizing the glucometer, entered Resident #89's room, which had a Droplet Precautions sign posted on door and PPE supplies just inside the door. After donning PPE, RN-E checked Resident #89's blood glucose reading with that same glucometer. Upon exiting Resident #89's room, RN-E removed his PPE and gloves, then placed the glucometer on the top of his medication cart, entered data into his computer, and without sanitizing the glucometer or medication cart surface, started moving down the hall to continue medication administration. During an interview with RN-E on 8/14/2024 at 12:26PM, RN-E confirmed he used the same glucometer for Residents #204 and Resident #89 to check their blood glucose readings and did not sanitize the glucometer before and after each resident but stated he should have, especially since Resident #89 was on droplet precautions. RN-E stated he should have used the disinfecting wipes to sanitize the glucometer in between uses but had forgotten to stock his medication cart with the container of disinfecting wipes that morning and did not have it available. RN-E stated that his failure to sanitize the glucometer in between uses with residents could spread germs. During an interview on 8/15/2024 at 10:10 am, the DON confirmed RN-E should have sanitized the glucometer with the disinfecting wipes and allowed it to dry 3-5 minutes in between uses with different residents, and before entering and after exiting a room where droplet precautions were in place, to prevent cross-contamination and outbreaks of disease. 2. Observation on 08/14/2024 between 12:09pm and 12:19pm revealed RN-E, while administering medications, did not wash or sanitize his hands before entering Resident #204's room, donned gloves to conduct accu-check, and then after removing gloves did not wash or sanitize his hands upon exit or before entering Resident #89's room. Resident #89's room had a Droplet Precautions sign posted on the door and PPE supplies just inside the door. RN-E was observed to put on gown and gloves at the entrance to room to administer accu-check for Resident #89. Upon exiting Resident #89's room, RN-E removed his PPE and gloves just inside the door but did not wash or sanitize his hands after exiting. During an interview with RN-E on 08/14/2024 at 12:26PM, RN-E confirmed he did not wash or sanitize his hands in between medication administration for Residents #204 and #89, or in between glove changes between the 2 residents. RN-E stated that his failure to sanitize his hands in between residents could spread germs. During an interview on 08/15/2024 at 10:10 am, the DON confirmed RN-E should have washed his hands either manually or with alcohol in between working with each resident and between glove changes to prevent cross-contamination and outbreaks of disease. 3. Observation and interview on 08/14/2024 at 12:54 p.m. revealed Server B passing trays on 100 hall from the meal cart wearing gloves on her hands. Server B while passing lunch trays was observed pushing the cart, opening the door to the cart, pulling trays out, knocking on doors, opening doors to rooms, and closing the room doors by using doorknob. Server B passed approximately 7 trays and entered rooms and exited rooms without changing gloves and without washing hands. Server B stated she was wearing the gloves due to having acrylic nails. Server B further stated she should have sanitized her hands between rooms even though she was wearing gloves. Server B stated hands are supposed to be always sanitized when passing trays whether the person has gloves on or not. Server B stated, it keeps the germs down. During an interview on 08/15/2024 at 1:44 p.m. the GM stated staff don't really need to wear gloves when passing trays. The GM further stated staff should sanitize hands when going in a room and when coming out of the room when passing trays. The GM stated this is part of infection control. Review of facility policy, titled Infection Control Policy, dated July 2020, revealed hand hygiene is to be performed before and after contact with a resident and immediately after removing gloves and that for droplet precautions, wash hands with antimicrobial soap before entering room and after leaving room and remove gloves before leaving resident's environment and wash hands immediately with antimicrobial soap. Further review reveals blood glucose meters will be cleaned and disinfected prior to and after each use . and if use of common equipment or items is unavoidable, adequately clean and disinfect before use for any other resident with chemical agent approved for use on the identified microorganism. Review of facility's policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, not dated, read Policy Statement: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation, 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure osmolite (a tube feeding formula) was disposed of after its best-by date. The facility failed to ensure staffs facial hair was covered by a hair restraint. The facility failed to ensure trays, insulated plate lids, and insulated plate bases were air dried prior to stacking them with water droplets resulting in being wiped dry with a hand towel during meal prep. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 08/12/2024 at 3:20 PM, revealed 4 8 fl. oz. closeable cartons of Osmolite with a best-by date on the top of the carton of 1FEB2024 in the 3rd floor nutrition fridge. Interview on 8/12/2024 at 5:00 PM, the DON stated that there should be no Osmolite in any nutrition fridge after its best-by date. Observation and interview on 08/14/2024 at 10:15 a.m. revealed the [NAME] was not wearing a facial hair restraint as he crossed the kitchen carrying a bag of fried onions for the green beans he was prepping for lunch. The [NAME] then left the kitchen area and went to the back in which he returned wearing a facial hair restraint over his beard with his mustache exposed. The [NAME] stated he was not wearing a beard guard initially because he had just returned from his break. The [NAME] further stated he did not know his mustache needed to be covered. The [NAME] stated facial hair (beard restraints) restraint were worn so hair did not fall in the food and contaminate it. Observation and interview on 08/14/2024 at 10:25 a.m. revealed Server A was setting up dishes to be washed in the dishwasher and then pulling dishes from the dishwasher while wearing a facial hair restraint only covering his beard but not his mustache. Server A stated he did not believe it was supposed to cover his mustache. Server A further stated the use of the beard restraint was so hair did not fall out onto the dishes when washing or the food when preparing it. Server A stated by not wearing a beard restraint it could cause cross contamination and it could cause the patient to get sick. During an interview on 08/14/2024 at 10:30 a.m. the EXC stated staff when they were around food or dishes should be wearing hair restraints. The EXC further stated hair restraints in general were good hygiene, kept hair away from the face so staff were not tempted to touch their face or hair, kept hair from falling in food or on dishes preventing cross contamination. During an interview on 08/14/2024 at 4:46 p.m. the Dietician stated staff when in the kitchen if they have facial hair should wear beard restraints. The Dietician further stated she had mentioned this to the kitchen staff in the past. The Dietician stated beard guards keep hair from getting in the food which could cause cross contamination. Observation on 08/15/2024 at 11:22 a.m. revealed the EXC drying trays with a hand towel as she was prepping the trays for lunch meal service. The stacked trays, insulated plate lids, and insulated plate bases were observed to have droplets of water on them. Observation on 08/15/2024 at 11:26 a.m. revealed the [NAME] preparing plates for lunch wearing gloves as he prepared crispy chicken patty sandwiches to place on trays. The [NAME] left the kitchen to get salad from the refrigerator upon his return, he moved a bag of buns to the side with gloved hands, pulled the wrap back to cut a cucumber placed it on the salad, then proceeded to get diced tomatoes out of a container with his gloved hand, placed tomatoes on salad, then continued to make the chicken sandwiches, getting bags of buns, taking buns from bags with his gloved hand, prepped another salad which needed boiled eggs, grabbed with his hand the boiled egg slices from another salad and placed on the salad, then grabbed shredded cheese from a bag with his hand and placed on salad, covered the salad, then placed it on a tray. The [NAME] continued to prepare lunch plates by grabbing an insulated plate base which had a droplet of water on it, wiped it dry with a white hand towel which had been sitting on the counter, proceeded to place plate on the insulated plate base, prepped meal, and then wiped off an insulated lid placing it on top of the plate. During this observation the [NAME] did not stop to wash hands and did not change his gloves. During an interview on 08/15/2024 at 11:36 a.m. the [NAME] stated he should have changed gloves due to it was cross contamination by not changing his gloves. During an interview on 08/15/2024 at 11:38 a.m. the EXC stated the cook should have washed his hands and changed gloves due to it was cross contamination by touching other items during the plate prep. The EXC further stated the water droplets on the trays, insulated lids and bases for the plates should have been completely dry and using the rag could cause contamination of the trays, bases, and lids. During an interview on 08/15/2024 at 1:44 p.m. GM stated the cook should have used utensils (tongs). The GM further stated hand washing should have been done and by not changing gloves or washing hands could cause cross contamination. Review of facility's policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, not dated, read Policy Statement: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation, 6. Employees must wash their hands: c. whenever entering or re-entering the kitchen: g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. 9. Food service employees will be trained in proper use of utensils such as tongs, gloves, deli paper, and spatulas as tools to prevent foodborne illness. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assist the accurate acquiring, receiving, dispensing ,and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents(Resident #1) reviewed for pharmacy services. The facility failed to acquire and administer Resident #1's scheduled dose of Dexamethasone (a corticosteroid that prevents the release of substances in the body that cause inflammation.) on 7/7/2024 and 7/8/2024. This failure could place residents at risk for pain and poor quality of life. The findings were: Record review of Resident #1's face sheet, dated 7/17/2024 revealed a [AGE] year-old female with an admission date of 6/27/2024 and diagnoses which included neoplasm of cerebral meninges, ( A meningioma is a tumor that grows from the membranes that surround the brain and spinal cord, called the meninges. A meningioma is not a brain tumor, but it may press on the nearby brain, nerves and vessels. ) hyperlipidemia, (high cholesterol)unspecified dementia(Dementia is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities.), anxiety disorder, hypertension (high blood pressure) and muscle weakness. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 00 which indicated the resident was cognitively impaired. Record review of Resident #1's physician's orders from 6/27/2024 to 7/31/2024 revealed a physician order for Dexamethasone oral tablet 4mg give 1 tablet every six hours. The order start date was 6/27/2024. Record review of Resident #1's July 2024 MAR revealed Dexamethasone oral tablet 4mg give 1 tablet every six hours and was documented as not given due to medication unavailable on 7/7/2024 and 7/8/2024every 6 hours. (12:00 am,6:00 am,12:00pm,6:00 pm missing a total of 8 doses in 2 days) Record review of Resident #1's Nurse Practitioner notes dated 7/12/2024 at 11:00 am revealed: no signs of distress noted, family at bedside, patient follows commands but appears weak, family states patient was sitting up eating and talking this morning prior to PT. Patient typically becomes sleepier after therapy based on my encounters with her and family confirms. Discussed concerns with patient family member regarding dexamethasone. Patient seemed to decline after missing 2 days of by mouth dexamethasone. Administration aware of issue. Patient was started on IV dexamethasone and seems back to baseline. During an interview on 7/18/2024 at 10:40 am the DON stated the facility should maintain 7 days of medication in the facility. She stated staff should monitor medications to ensure medications are re-ordered as needed. The DON stated Dexamethasone was not a common medication in the facility therefore it was not in the E Box(emergency supply box) to be available for staff to obtain it. The DON stated the pharmacy was new and it was a holiday weekend along with the pharmacy themselves needing to order the Dexamethasone as they did not have it in stock. She stated she had been working with the pharmacy like a QAPI meeting in order to ensure there were no delays on medications being delivered. The DON further stated the physician for Resident #1 had been notified of not receiving the medication with no physician orders given. During an interview on 7/18/2024 at 11:10 am MA C stated medications were in PCC profile of residents for administration. The process of ordering medications was to look at the available medication and check to see if there was a 7 day supply available. There was not . MA C wrote the medication down and gave it to the nurse to order. If the medication was not available, then the process was to look in the overflow drawer and if it was not found then tell the nurse and they will order the medication. There was a stock box that had different medications in it but the Dexamethasone was not in the stock box. An interview was attempt for Nurse Practitioner on 7/18/2024 at 12:49 pm but was unsuccessful. During an interview on 7/18/2024 at 1:40 pm MA D stated medications are in PCC profile of residents for administration. The process of ordering medications was to check the available medication and check to see if there was a 7 day supply available or if more days were needed. If the medication was not available, then the process was to look in the extra drawer and if it was not found then tell the nurse and they would order the medication. The pharmacy provided am and pm delivery. MA D stated she documented in the residents EMR on 7/7/2024 and 7/8/2024 at 6:00 pm that she had not given the Dexamethasone for Resident #1 due to the medication not being available. She further stated she was aware that the medication had been ordered and was waiting for delivery as she had seen the order sheet. During an interview on 7/18/2024 at 2:10 pm MA E stated she documented in the residents EMR on 7/7/2024 and 7/8/2024 at 12:00 pm that she had not given the Dexamethasone for Resident #1 due to the medication not being available. She further stated she was aware that the medication had been ordered and was waiting for delivery as the nurse(LVN G) had told her. An interview attempt for LVN G on 7/18/2024 at 1:15 pm was unsuccessful after 2 attempts. Record review of a facility policy titled Medication Ordering and Receiving from Pharmacy Provider dated 1/23 revealed: Policy: Medications and related products are received from the provider pharmacy on a timely basis. Emergency/Stat medication order when medication is not available in the emergency kit. An Emergency/Stat order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request STAT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for quality of care in that: The facility failed to ensure Residents #1, #2, #3 and #4 received their scheduled wound care as ordered by the physician. This deficient practice could place residents at risk for worsening skin conditions and infections. Findings included: Record review of Resident #1's admission Record, dated 1/19/24, revealed Resident #1 was admitted to the facility on [DATE], with the following diagnoses: Acute embolism (blockage in a blood vessel caused by a piece of material) and thrombosis (blood clot in an artery/vein) of right femoral vein, Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) , Hyperlipidemia (high levels of fat in the blood), Hypertension (high blood pressure), Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and GERD (digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #1's MDS assessment, dated 1/4/24, revealed Resident #1 had a BIMS of 11, suggesting moderate cognitive impairment. Further record review of this document revealed, under Section M - Skin Conditions, Application of dressings to feet (with or without topical medications). Record review of Resident #1's Care Plan, dated 1/19/24, revealed: The resident had actual impairment to skin integrity r/t surgical wound - S/P RLE thrombectomy (surgery to remove a blood clot from a blood vessel) - complication graft bypass, arterial wound of the right plantar foot and right toes .treat per physician's orders. Record review of Resident #1's hospital discharge orders, dated 12/31/23, revealed: wet to dry gauze between toes right foot. Record review of Resident #1's facility order written by the PCP (dated 1/2/24, start date 1/3/24) revealed: cleanse toes of right foot with wound cleanser, apply a wet to dry dressing daily to right toes; one time a day. Record review of Resident #1's January 2024 TAR revealed: cleanse toes to right foot with wound cleanser, apply a wet to dry dressing daily to right toes; one time a day; order date 1/2/24 at 11:03 am; d/c date 1/5/24 at 11:23 am. Further review of the record revealed no documentation that Resident #1 received wound care for the right toes on 1/1/24 and 1/4/24. Record review of Resident #2's admission Record, dated 1/21/24, revealed Resident #2 was admitted to the facility on [DATE], with the following diagnoses: Sepsis (life-threatening complication of an infection), Cellulitis (common bacterial skin infection) of BLE, UTI, Pneumonia (infection in the lungs) , Thrombocytopenia (low platelets in the blood), Hyperkalemia (high level of potassium in the blood) , Hypertension (high blood pressure), Heart Failure, Lymphedema (swelling in the extremities cause by a lymphatic blockage), GERD (digestive disease in which stomach acid or bile irritates the food pipe lining), Acute Kidney Failure. Record review of Resident #2's MDS assessment, dated 1/3/24, revealed Resident #2 had a BIMS of 15, suggesting no cognitive impairment . Further record review of this document revealed, under Section M - Skin Conditions, Resident #2 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Other Problems - Skin tears; Pressure ulcer/injury care. Record review of Resident #2's physician orders (dated 12/29/23, start date 12/30/23) revealed: ammonium lactate external cream 12%; apply to bilateral lower legs topically ever day shift; every Tuesday, Thursday, Saturday. Record review of Resident #2's January 2024 TAR revealed: ammonium lactate external cream 12%; apply to bilateral lower legs topically every day shift; every Tuesday, Thursday, Saturday; order date 12/29/23. Further review of the record revealed no documentation that Resident #2 received wound care to bilateral lower legs on 1/4/24. Record review of Resident #2's physician order (dated 12/29/23) revealed: apply calcium alginate to left back thigh open wound area. Record review of Resident #2's January 2024 TAR revealed: apply calcium alginate to left back thigh open wound area; every day shift; every Tuesday, Thursday, Saturday; order date12/29/23; d/c date 1/18/24. Further review of the record revealed no documentation that Resident #2 received wound care to left back thigh open wound area on 1/4/24 or 1/11/24. During an interview on 1/20/24 at 5:06 p.m., Resident #2 said she had received wound care but not as directed by the physician . During an observation on 1/21/24 at 12:42 p.m., LVN D provided wound care for Resident #2's BLE. LVN D removed dressing, cleaned the leg with NS, applied ammonium lactate external cream 12%, applied bandage roll x2, secured with initialed/dated tape. After washing her hands, LVN D repeated the same treatment on the left leg. Wound care was completed using infection control practices and no concerns were noted. Record review of Resident #3's admission Record, dated 1/19/24, revealed Resident #3 was admitted to the facility on [DATE], with the following diagnoses: Metabolic Encephalopathy (problem in the brain caused by chemical imbalance in the blood), Acute Kidney Failure, Type 2 diabetes (chronic condition that affects the way the body processes blood sugar), Hyperlipidemia (high levels of fat in the blood), Hypertension (high blood pressure), and Dysphagia (difficulty swallowing) . Record review of Resident #3's MDS assessment, dated 1/16/24, revealed Resident #3 had a BIMS of 1, suggesting severe cognitive impairment. Further record review of this document revealed, under Section M - Skin Conditions, Resident #3 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Pressure ulcer/injury care; Applications of ointments/medications. Record review of Resident #3's physician orders (dated 1/10/24, start date 1/11/24) revealed: wound care to sacrum as follows: cleanse with wound cleanser/NS on gauze, pat dry with gauze, apply Medi honey and cover with dressing Q day and PRN. Record review of Resident #3's January 2024 TAR revealed: wound care to sacrum as follows: cleanse with wound cleanser/NS on gauze, pat dry with gauze, apply Medi honey and cover with dressing Q day and PRN; order date 1/10/24. Further review of the record revealed no documentation that Resident #3 received wound care to sacrum on 1/13/24 and 1/14/24. During an observation on 1/20/24 at 5:50 p.m., LVN C provided wound care for Resident #3's sacrum. LVN C removed dressing, wound was cleaned with wound cleanser and gauze, patted dry Medi honey applied, and initialed/dated dressing applied. Wound care was completed using infection control practices and no concerns were noted. Record review of Resident #4's admission Record, dated 1/20/24, revealed Resident #4 was admitted to the facility on [DATE], with the following diagnoses: Osteomyelitis (serious infection of the bone) of left ankle and foot, Methicillin Susceptible Staphylococcus Aureus (infection caused by bacteria found on the skin) Infection, Type 2 diabetes (chronic condition that affects the way the body processes blood sugar), Hyperlipidemia (high levels of fat in the blood), Hypertension (high blood pressure), Acute Kidney Failure, and UTI. Record review of Resident #4's MDS assessment, dated 1/4/24, revealed Resident #4 had a BIMS of 13, suggesting no cognitive impairment. Further record review of this document revealed, under Section M - Skin Conditions, Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Pressure ulcer/injury care. Record review of Resident #4's hospital discharge instructions, dated [DATE], revealed: Wound/Dressing Care: Right foot: pack collagen with silver Hydrofera blue ready, cover with foam boarder, cut piece of Prisma, moisten with saline to activate, cut piece of Hydrofera blue ready to fit size of wound, place on top of collagen, cover with mepilex. Record review of Resident #4's January 2024 TAR revealed: R foot, cleanse with NS, apply collagen with silver to wound bed, cut piece of Hydrofera blue ready to fit size of wound, and apply to wound bed, cover with mepilex dressing; per hospital d/c instructions; every shift for R foot wound; order date 12/30/23, d/c date 1/12/24. Further review of the record revealed no documentation that Resident #4 received wound care to R foot on 1/7/24. During an interview on 1/21/24 at 12:10 p.m., Resident #4 said she had an infection in her left ankle. She said when she was admitted to the facility, she did not receive wound care every day as ordered by the physician . Resident #4 said she now received wound care to her ankle every day by LVN D. During an interview on 1/22/24 at 5:35 p.m., RN B said the floor nurses were responsible for ensuring wound care was completed during the weekends. RN B said she might have completed wound care for Resident #4 on 1/7/24 at the end of her shift and might not have documented it. She added the facility policy was to complete and document all treatments ordered. During an interview on 1/20/24 at 1:03 p.m., LVN D said she worked Monday - Friday and the floor nurses and nurse supervisors were responsible for ensuring wound care was completed on the weekends. LVN D said she was not aware of the missed treatments for Residents #1, #2, #3, and #4 or if these missed treatments were reported to the physicians. LVN D said the admissions nurse was responsible for reviewing and transcribing hospital discharge orders when residents are admitted to the facility. During an interview on 1/21/24 at 3:36 p.m., the wound care physician said she had not been notified of the missed treatments for Residents #1, #3, and #4. She added that Resident #4 was not on her panel of residents. Attempts to contact Resident #4's physician was unsuccessful. During an interview on 1/20/24 at 6:09 p.m., the CNO said residents are discharged from the hospital with wound care orders those orders were then verified, transcribed, and implemented at the facility by the admissions nurse. She added the clinical team, which included: the CNO, 3 ACNOs, and the MDS coordinators, reviewed orders daily to ensure orders were transcribed and implemented. The CNO said LVN D provided wound care Monday - Friday and the floor nurses during the weekends. The CNO said daily reports were run and reviewed during clinical meetings as well as the TARs to ensure wound care was provided as ordered. She added she and the ACNOs were responsible for ensuring coordination of care and this was important to avoid infections and worsening of wounds. The CNO said she was not aware of the missed treatments for Residents #1, 2, 3, and 4 and that these missed treatments must not have been captured on the daily reports. The CNO said she was not sure if the physician was notified of the missed treatments. Attempts to contact LVN E, Admissions Nurse, were unsuccessful. Record review of a facility policy titled, Wound Policy & Procedure revised May 2023, revealed: Policy: The facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being .Any resident with a wound receives treatment and services consistent with the resident's goals and treatment .A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice .Wound Management Principles .Maintenance of physiologic local wound environment including, and not limited to: .Cleansing wound .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments in 2 of 9 medication carts (third floor treatment cart and medication cart) reviewed for medication storage, in that: The facility failed to ensure the third-floor treatment cart and medication cart were locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. Findings included: During an observation on 1/19/24 at 11:30 a.m., the treatment cart on the third floor was unlocked and unattended. The treatment cart contained prescription and over the counter medications related to skin and wound care, and suture removal kits. There were visitors and non-nursing staff walking up and down the hallway and there were no nurses at the nurses' station or in the hallways. The treatment cart was again observed unlocked on 1/20/24 at 5:21 pm. The CNO was notified by the surveyor. During observation and interview on 1/19/24 at 11:43 a.m., LVN A was observed returning to the third floor. At 11:47 a.m., LVN A said the treatment cart was not supposed to be left unlocked because it contained medications. LVN A was observed locking the treatment cart at 11:51 a.m. During an observation on 1/20/24 at 5:16 p.m., the medication cart on the third floor, outside room [ROOM NUMBER], was unlocked and unattended. During an interview on 1/20/24 at 5:18 p.m., RN A said she was aware that the medication cart was unlocked. She said the facility policy was that medication carts be locked when unattended. RN A said there were ambulatory residents on the third floor; she added it was important to keep medication carts locked so that residents, visitors, and staff did not have access to medications. During an interview on 1/20/24 at 6:09 p.m., the CNO said all medications carts and treatments carts were to be locked when unattended. She added staff were expected to lock their medication carts and keep the keys with them or hand them to the charge nurse. Record review of facility policy titled Medication Labeling and Storage, dated January 2020, did not address the storage of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to formulate an advanced directive for 1 of 8 residents (Resident #71) reviewed for advance directives. 1. Resident #71's orders for code status was Full code, but verbally wanted to be a DNR code status. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: 1.Record review of Resident #71's admission Record dated [DATE] revealed he was admitted on [DATE] with Advanced Directive as a Full Code. Resident #71 has diagnoses of kidney failure, diabetes II (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), peripheral vascular disease(a systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the brain). This happens as a result of arteriosclerosis, or a buildup of plaque, and can happen with veins or arteries.) and major depressive disorder (expression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily.) Record review of Resident #71's consolidated physician orders for [DATE] was documented Full Code. Record review of Resident #71's telephone order dated [DATE] was documented as a Full Code. Record review of Resident #71's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS score was 11/15 (moderately impaired), Record review of Resident #71's Care plan dated [DATE] revealed Resident #71 was a Full Code and interventions were to review advanced directive with resident and or family/responsible party quarterly and as needed. Record review of Resident #71's evaluation (resident assessment) dated [DATE] was documented full code . (nurse was not available) Interview on [DATE] at 10:29 AM with Resident #71 in his room revealed he wanted to be a DNR (do not resuscitate) Interview on [DATE] at 5:00 PM with SW stated looking at Resident #71 chart, it was documented he wanted to be a full code status. The SW stated the code status of a resident would have been caught on admission and later by the SW . The SW stated MDS G inputted resident code status into resident care plans. SW did review during care plan. SW that signed was not available. SW stated the resident code status should be completed on admission and as needed. Interview on at [DATE] at 7:00 PM MDS G stated the RN and nurses should have caught it on admission , the code status Resident #71 desired, staff rely on SW for resident's code status. MDS G stated he was not sure why this was missed. If the resident changed his or her mind on code status the SW would update on resident records. MDS G stated if the resident did not say on admission, the resident would be automatically a Full Code status. Interview on [DATE] at 8:12 PM with the SW in reguards to Resident # 71, the SW stated she talked to Resident #71 and he wanted to be a DNR. The SW stated she will change this on his records. Record review of policy Advanced Directives dated [DATE] revealed. The facility is committed to the preservations of life and alleviations of suffering. Therefore, every resident admitted to this facility will receive total life support, including resuscitations, unless a decision not to resuscitate (to revive form apparent death) has been previously made. Social services and Nursing in collaboration with facility administration are responsible for honoring Healthcare Advanced Directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 8 Residents (Resident #47) reviewed for storage of medications. Resident #47's triamcinolone cream [a cream used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions], was stored in his room at his bedside. This deficient practice could place residents at risk for harm due to improper storage. The findings are: A record review of Resident #47's admission record, dated 07/13/2023, revealed an admission date of 06/28/2023, with diagnoses which included a rash. A record review of Resident #47's admission MDS, dated [DATE], revealed Resident #47 was a [AGE] year-old male, admitted from the hospital. A record review of Resident #47's physician's orders dated 07/10/2023 revealed Resident #47 was prescribed triamcinolone cream 0.1% topical apply to bilateral lower extremities topically three times a day for rash. During an observation and interview on 07/10/2023 at 03:33 PM, Resident #47 was in his room seated at his bedside. Further observation revealed a 454-gram container of the medicated cream triamcinolone kept atop of Resident #47's bedside nightstand. Resident #47 stated the morning nurse applied the cream and left the cream at the bedside. During an interview and observation on 07/10/2023 at 03:40 PM, LVN K stated the medication atop of the nightstand was the medicated cream triamcinolone. LVN K stated the medication should be stored in the medication / treatment cart and removed the medication to store it in the medication cart . During an interview on 07/12/2023 at 04:33 PM ADON I stated all medications are to be stored in the medication carts. A record review of the facilities medication labeling, and storage policy dated January 2020, revealed, policy: medications are labeled in accordance with facility requirement and state and federal law. all drug containers will be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirement. there will be a standard method for appropriately and safely labeling medications dispensed to all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were provide the therapeutic diets as prescribed by the attending physician for 1 of 8 residents (#71) reviewed in that: Resident # 71 did not receive his sugar free health shake lunch meal as ordered by physician. This failure could affect residents with diet needs and could result in a decrease in calories and potential weight loss. The Findings were: Record review of Resident #71's admission Record dated 7/13/2023 revealed he was admitted on [DATE] with acute kidney failure, diabetes II and chronic kidney disease Record review of Resident #71's consolidated physician orders for July 2023 documented House Shake-Sugar Free three times a day with meals. Record review of Resident #71's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS score was 11/15 (moderately impaired). Record review of Resident #71's Care plan dated 6/13/2023 revealed Resident #71 for diet, controlled carbohydrate, regular texture, thin liquids., The resident has the potential for nutritional deficit related to diabetic foot ulcer, diet restrictions. The interventions were diabetic diet as ordered and RD (regional dietician) to evaluate and make diet change recommendations as needed. Record review of Resident #71's MAR (medications administration record) dated 7/2023 revealed House Shake -Sugar Free three times a day with meals was provided as ordered. MAR was not completed at time, nurse's work 12-hour shifts. Record review of Resident #71's Diet Type Report dated 7/10/2023 revealed he had a diet supplement of House Shake-Sugar Free with meals. Observation on 7/11/2023 at 1:05 PM in Resident #71's room revealed he received lunch tray for today, with no House Shake-Sugar Free. Interview on 7/11/2023 at 1:06 PM with Resident #71 revealed he often did not get the House Shake-Sugar Free during meals. Resident #71 stated the kitchen runs out to food in the kitchen at times. Interview on 7/13/2023 at 11:33 AM with RD she was not aware the kitchen was out of sugar free shake and the DM (dietary manager) orders food from food company. Observation on 7/12/2023 at 2:42 PM with the DM in the kitchen pantry, observed 3 rows of sugar free shakes. Interview on 7/12/2023 at 2:42 PM the DM stated there were sugar free shakes in the panty and they order them from the food company. They were not sure who told the resident there was not more sugar free shakes. Record review of policy Supplements dated 2021 revealed Nutritional supplements will be provided as ordered to clients whose nutrients needs may be increased.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for 2 of 8 Residents (Residents #236 and #238) reviewed for base line care plans, in that: 1. The facility failed to develop and implement a baseline care plan to support Resident #236's needs for hypotension, low blood pressure, with prescribed medications meant to raise blood pressure, oxygen use, prescribed opioid use for pain, and support interventions for a fractured hip. 2. The facility failed to develop and implement a baseline care plan to support Resident #238's needs for communication in Arabic. These failures could place residents at risk of not having their needs identified within the required timeframe, to provide person centered care. The findings included: 1. A record review of Resident #236's admission record, dated 07/11/2023, revealed an admission date of 07/04/2023, with diagnoses which included hypotension [low blood pressure], displaced intertrochanteric fracture of right femur [broken right hip], and hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side [a right side of the body paralysis a stroke], and dependence on supplemental oxygen. A record review of Resident #236's admission MDS, dated [DATE], revealed Resident #236 was an [AGE] year-old female admitted from the hospital and assessed with a BIMS of 15 out of 15 score indicating no mental cognition impairment. A record review of Resident #236's physician orders, dated 07/11/2023, revealed the physician ordered for Resident #236 to receive the following: 1. Oxygen at 2 to 3 liters per minute to maintain oxygen levels greater than 92%. 2. Floor nurse to monitor right trochanter [hip] closed surgical site every shift and report as needed three times a day. 3. Midodrine [a drug which raises blood pressure] tablet 5 milligram give one tablet by mouth three times a day for hypotension [low blood pressure]. 4. Tramadol [an opioid] oral tablet 50 milligrams give half a tablet by mouth every 24 hours as needed for breakthrough pain. 5. Tramadol [an opioid] oral tablet 50 milligrams give one tablet by mouth every six hours as needed for moderate pain. A record review on 07/10/2023, of Resident #236's Initial Nursing Care Plan, dated 07/04/2023, revealed no focuses, goals, and / or interventions for Resident #236's needs for support for her broken hip, potential complications from her opioid use to control pain, oxygen use, and need for midodrine a drug which raises blood pressure [can be dangerous if given when the blood pressure is high]. During an observation and interview on 07/11/2023 at 11:12 AM, Resident #236 was in bed awake, alert, receiving oxygen at 2 liters a minute via a nasal cannula [a thin tube]. Resident #236 stated she was recovering from a broken hip surgery and needed oxygen to breathe and used pain medications. Resident #236 stated she was not aware she was to receive a blood pressure medication. Resident #236 stated she was not aware she was prescribed a medication to raise her blood pressure but did state she has had episodes of dizziness, light head feelings, to include shortness of breath. During an interview on 07/11/2023 at 02:30 PM, ADON J stated he assessed Resident #236 upon admission on the afternoon of 07/04/2023 and reviewed Resident #236's hospital discharge paperwork and received orders for Resident #236 to include: 1. Oxygen at 2 to 3 liters per minute to maintain oxygen levels greater than 92%. 2. Floor nurse to monitor right trochanter [hip] closed surgical site every shift and report as needed three times a day. 3. Midodrine [a drug which raises blood pressure] tablet 5 milligram give one tablet by mouth three times a day for hypotension [low blood pressure]. 4. Tramadol [an opioid] oral tablet 50 milligrams give half a tablet by mouth every 24 hours as needed for breakthrough pain. 5. Tramadol [an opioid] oral tablet 50 milligrams give one tablet by mouth every six hours as needed for moderate pain. During an interview on 07/12/2023 at 04:10 PM, ADON I stated nursing and interdisciplinary staff all contributed to a resident's care plan. ADON I stated she was not aware who initiated Resident #236's care plan and further stated the care plan should have care details for Resident #236's needs. ADON I stated she and the DON were responsible for quality reviews of all care plans and could not account for the failure. 2. A record review of Resident #238's admission record, dated 07/10/2023, revealed an admission date of 07/05/2023, with diagnoses which included pneumonia [an infection of the lungs]. A record review of Resident #238's admission MDS, dated [DATE], revealed Resident #238 was a 77-yr-old male admitted from the hospital. A record review of Resident #238's Nursing Evaluation notes, dated 07/05/2023, authored by the ADON I, revealed Resident #238 was assessed as speaking Arabic and unable to speak or read English, does not speak English. a translator / interpreter is not needed. A record review of Resident #238's Initial Nursing Care Plan, dated 07/06/2023, revealed no supports for Resident #238's need for communication and / or translation services due to his only speaking the Arabic Language. During an observation and interview on 07/10/2023 at 09:27 AM Resident #238 presented in bed in his room with his family member visiting. Resident #238 could not interview with the surveyor. Resident #238's family member stated they spoke and understood both English and Arabic. Resident #238's family member stated Resident #238 only spoke Arabic. The surveyor asked Resident #238's family member to ask for permission from Resident #238 for his family to interpret for Resident #238's, Resident #238 made eye contact with the surveyor and nodded his head in an affirmative and Resident #238's family member stated Resident #238 gave permission. Resident #238 stated he was not able to understand English and could not communicate with staff if his family was not present. Resident #238 stated the stay at the facility has been frustrating. When asked what needs were not being met, Resident #238 stated many but for now he would like his communication needs improved. During an interview on 07/11/2023 at 10:02 AM RN H stated Resident #238 only spoke Arabic and staff would utilize family to interpret. RN H stated Resident #238 spoke some and understood some English. RN H stated she and other staff used various methods to communicate to include internet-based translators when family was not available to translate. During an interview on 07/12/2023 at 04:20 PM, ADON I stated nursing and interdisciplinary staff all contributed to a resident's care plan. ADON I stated she was the RN who initiated Resident #238's care plan and did not recognize she failed to develop a care plan for Resident #238's need for Arabic Language communication. ADON I stated she and the DON were responsible for care plan reviews to ensure accuracy and quality. ADON I stated she could not account for why she missed Resident #238's need for Arabic communication. ADON I stated the lack of a care plan for communication could make the interaction between staff and residents difficult. During an interview on 07/13/2023 at 05:20 PM the Administrator stated all residents should have a care plan in place, developed and implemented to support resident's needs. The Administrator stated Resident #238's care plan has been revised and updated to include Arabic communication supports instructions for all staff who care for Resident #238. A record review of the facility's policy Care Plan, dated April 2023, revealed, General: Each resident will have a care plan that is current, individualized, and consistent with their medical regimen . Policy: A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission to the facility. This care plan includes minimum health care information necessary to properly care for the Resident. Required components of the baseline care plan: Initial goals based on admission orders. Services planned to attain or maintain residence higher practicable physical, mental, and psychosocial well-being, including, but not limited to: activities of daily life, nutrition, fall risk, skin integrity, and pain management .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error rate was 10.7% based on 3 errors out of 28 opportunities for 2 of 5 residents (Resident #256 and #257) reviewed for medication administration: 1. LVN M administered a late medication for Resident #256. The medication was scheduled for 07:30 AM administration, the medication was administered at 08:44 AM. 2. MA N administered late medications for Resident #257. The medications were scheduled for administration any time between 07:00 AM and 10:00 AM. The medications were administered at 11:54 AM. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. Resident #256 A record review of Resident #256's admission record, dated 07/12/2023, revealed an admission date of 06/28/2023 with diagnoses which included diabetes mellitus type II [a deadly disease where the body cannot process sugar]. A record review of Resident #256's admission MDS, dated [DATE], revealed Resident #256 was an [AGE] year-old female admitted from the hospital. A record review of Resident #256's physician's orders, dated 07/13/2023, revealed Resident #256 was prescribed to receive Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) 100 UNIT/ML [a mix of regular quick acting insulin and man-made long-acting insulin], Inject 7 units subcutaneously [under the skin] two times a day for DM at 07:30 AM and again at 05:00 PM. During an observation and interview on 07/12/2023 at 08:44 AM revealed LVN M preparing an insulin injection for Resident #256. LVN M prepared 7 units of Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) and administered the injection to Resident #256. LVN M stated he was late in the administration due to the breakfast was late for Resident #256. LVN M stated he was concerned if he gave Resident #256 her insulin too early before she was able to eat, she would have a blood sugar that would be too low. The breakfast meal was not served to Resident #256 until 08:45 AM. LVN M stated the meal is usually served after 08:00 AM and he would usually administer the insulin injection right before the breakfast meal. LVN M stated he had not brought the schedule issue to anyone's attention. During an interview on 07/12/2023 at 08:50 AM, Resident #256 stated she received her insulin right before breakfast and the practice was routine since her admission in June 2023. Resident #256 stated she usually received breakfast at 08:30 AM although sometimes the breakfast was served later. 2. Resident #257 A record review of Resident #257's admission record, dated 07/12/2023, revealed an admission date of 06/30/2023 with diagnoses which included hypertension [high blood pressure] and polyneuropathy [painful nerves]. A record review of Resident #257's admission MDS, dated [DATE], revealed Resident #257 was a [AGE] year-old woman admitted into the facility on [DATE] from the hospital. A record review of Resident #257's physician orders, dated 07/13/2023, revealed Resident #257 was prescribed to receive: 1. Gabapentin Oral Capsule 300 MG; Give 1 capsule by mouth two times a day for Nerve Pain, anytime between 07:00 AM - 10:00 AM and again anytime between 04:00 PM and 07:00 PM. 2. Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for HTN, anytime between 07:00 AM - 10:00 AM and again anytime between 04:00 PM and 07:00 PM. During an observation and record review on 07/12/2023 at 11:54 AM, revealed MA N prepared and administered to Resident #257: 1. Gabapentin Oral Capsule 300 MG. 2. Metoprolol Tartrate Oral Tablet 50 MG. MA N stated the medications were late due to her workload assigned was overwhelming. MA N stated she was scheduled to work from 06:00 AM to 02:00 PM and assigned to administer medications to half of the facility's residents [the census was 91]. MA N stated she started on the 3rd floor [the facility has 3 floors] and by the time she arrived on the 1st floor to administer medications to 1st floor residents [Resident #257 was a 1st floor Resident] it was 11:54 almost noon. MA N stated she had not reported the late medication administration to anyone but her leadership was aware since March 2023 when she had raised concerns about the fluctuating census and increased workload. During an interview on 07/12/2023 at 04:33 PM ADON I stated LVN M and MA N did not alert her to the potential and actual late medication administrations for residents. ADON I stated she believed MA N could have administered the medications on time and referenced other staff were able to do so. ADON I stated MA N should have reported the potentially late medication administration to allow the ADON's to intervene for a on time safe medication administration. A record review of the facility's Medication Administration policy, dated 05/2023, revealed, Policy: It is the policy of the facility to ensure that medications are passed following the procedures outlined below: Procedure; . verify medication is being provided at the right time per physician orders and the medication administration record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 2 of 5 residents (Resident #236 and Resident #256) reviewed for medication administration, in that: 1. MA N administered midodrine (a drug prescribed to raise blood pressure) while Resident #236 was experiencing high blood pressure. 2. LVN M administered Resident #256's insulin late. These failures could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status. The findings included: 1. Resident #236 A record review of Resident #236's admission record, dated 07/11/2023, revealed an admission date of 07/04/2023, with diagnoses which included hypotension [low blood pressure]. A record review of Resident #236's admission MDS, dated [DATE], revealed Resident #236 was an [AGE] year-old female admitted from the hospital and assessed with a BIMS of 15 out of 15 score indicating no mental cognition impairment. A record review of Resident #236's physician orders, dated 07/11/2023, revealed the physician ordered for Resident #236 to receive Midodrine [a drug which raises blood pressure] tablet 5 milligram give one tablet by mouth three times a day for hypotension [low blood pressure]. A record review of the federal governments National Heart, Lung, and Blood Institute's website, https://www.nhlbi.nih.gov/health/high-blood-pressure , accessed 07/20/2023, revealed definitions of high blood pressure, High blood pressure develops when blood flows through your arteries at higher-than-normal pressures. Your blood pressure is made up of two numbers: systolic and diastolic. Systolic pressure is the pressure when the ventricles pump blood out of the heart. Diastolic pressure is the pressure between heartbeats when the heart is filling with blood. Your blood pressure changes throughout the day based on your activities. For most adults, a normal blood pressure is less than 120 over 80 millimeters of mercury (mm Hg), which is written as your systolic pressure reading over your diastolic pressure reading - 120/80 mm Hg. Your blood pressure is considered high when you have consistent systolic readings of 130 mm Hg or higher or diastolic readings of 80 mm Hg or higher. A record review of Resident #236's July 2023 Medication Administration Record revealed Resident #236 was administered midodrine 5mg by MA L on 07/11/2023 in the morning while Resident #236's blood pressure was 142/68. During an observation and interview on 07/11/2023 at 11:12 AM, Resident #236 was in bed awake, alert, receiving oxygen at 2 liters a minute via a nasal cannula [a thin tube]. Resident #236 stated she was recovering from a broken hip surgery and needed oxygen to breathe. Resident #236 was not aware she was to receive a blood pressure medication which would raise her blood pressure but did state she has had episodes of dizziness, light head feelings, to include shortness of breath. During an interview on 07/11/2023 at 02:30 PM, ADON J stated he assessed Resident #236 upon admission on the afternoon of 07/04/2023 and reviewed Resident #236's hospital discharge paperwork and received orders for Resident #236 to include Midodrine tablet 5 milligram give one tablet by mouth three times a day for hypotension. ADON J stated the order for the midodrine was not given with parameters to give and/or hold the medication. ADON J stated the medication raises a person's blood pressure. ADON J stated Resident #236 was prescribed the midodrine for low blood pressure. ADON J stated a blood pressure of 142 systolic and 68 diastolic would be considered high blood pressure for most residents. ADON J stated Resident #236's midodrine medication was stored on the medication aide cart and was assigned to medication aides to administer, although from time-to-time LVN's are assigned the medication aide cart. ADON J stated MA L had not reported Resident #236 had high blood pressure this morning, on 07/11/2023, and should have reported to Resident #236's nurse. ADON J stated the doctor did not provide any parameters and therefore had no guidance other than to call the doctor for clarification of the order. During an interview on 07/13/2023 at 04:00 PM, the Medical Director stated he prescribed Resident #236 the medication midodrine for her episodes of low blood pressure. The Medical Director received a report from the facility that Resident #236 had received the midodrine while she was experiencing an episode of high blood pressure. On 07/13/2023, The Medical Director discontinued the order for the midodrine without parameters and prescribed a new order for midodrine to include parameters. The Medical Director stated he wished for Resident #236 to receive the midodrine if her systolic blood pressure was not above 160. The Medical Director stated, a question should have been asked regarding the report of MA L administered the medication when Resident #236's blood pressure was high. The Medical Director stated midodrine raises blood pressure and Resident #236 has episodes of hypotension and needs the medication. 2. Resident #256 A record review of Resident #256's admission record, dated 07/12/2023, revealed an admission date of 06/28/2023 with diagnoses which included diabetes mellitus type II [a deadly disease where the body cannot process sugar]. A record review of Resident #256's admission MDS, dated [DATE], revealed Resident #256 was an [AGE] year-old female admitted from the hospital. A record review of Resident #256's physician's orders, dated 07/13/2023, revealed Resident #256 was prescribed to receive Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) 100 UNIT/ML [a mix of regular quick acting insulin and man-made long-acting insulin], Inject 7 units subcutaneously [under the skin] two times a day for DM at 07:30 AM and again at 05:00 PM. During an observation and interview on 07/12/2023 at 08:44 AM revealed LVN M preparing an insulin injection for Resident #256. LVN M prepared 7 units of Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%) and administered the injection to Resident #256. LVN M stated he was late in the administration due to the breakfast was late for Resident #256. LVN M stated he was concerned if he gave Resident #256 her insulin too early before she was able to eat, she would have a blood sugar that would be too low. The breakfast meal was not served to Resident #256 until 08:45 AM. LVN M stated the meal is usually served after 08:00 AM and he would usually administer the insulin injection right before the breakfast meal. LVN M stated he had not brought the schedule issue to anyone's attention. During an interview on 07/12/2023 at 08:50 AM, Resident #256 stated she received her insulin right before breakfast and the practice was routine since her admission in June 2023. Resident #256 stated she usually received breakfast at 08:30 AM although sometimes the breakfast was served later. During an interview on 07/12/2023 at 04:33 PM ADON I stated LVN M and MA L did not alert her to the potential and actual late medication administrations for residents. ADON I stated she believed MA N could have administered the medications on time and referenced other staff were able to do so. ADON I stated MA L should have reported the high blood pressure for Resident #236 to allow the ADON's to intervene for a safe medication administration. A record review of the federal governments National Institutes of Health website, https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=8c7038f4-60d4-4604-814d-74921cdc1ad8&type=display#:~:text=Novolin%2070%2F30%20is%20a,in%20patients%20with%20diabetes%20mellitus , accessed 07/20/2023, revealed, INDICATIONS AND USAGE for Insulin (Isophane & Regular) Subcutaneous Suspension (70%-30%), Read the instructions for use that come with your Novolin 70/30 product .Take Novolin 70/30 exactly as prescribed. Novolin 70/30 is an intermediate-acting insulin. The effects of Novolin 70/30 start working ½ hour after injection. The greatest blood sugar lowering effect is between 2 and 12 hours after the injection. This blood sugar lowering may last up to 24 hours.

Based on observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: The DM used a white towel from the sanitizer bucket under the holding food cart as a sanitizer thermometer testing in between food items. This failure could place residents at risk of cross contamination and food borne illness. The Findings were: Observation on 7/13/2023 at 4:08 PM in kitchen for food temperature, testing with the DM, he used a white towel from a small red bucket. This was labeled sanitizer bucket and was under the holding food cart, to wipe the food thermometer in between food items. Interview on 7/13/2023 at 4:09 PM the DM stated he always had used a towel from the sanitizer bucket to take the food temperature of food items. Interview on 7/13/23 at 4:10 PM [NAME] O stated he had just put a new bucket that was sanitizer and had not used, before the DM used it to take food item temperatures. [NAME] O stated he had not used the sanitizer towel for anything else at the time . Interview on 7/13/2023 at 4:11 PM the Administrator discussed the DM using a towel from the sanitizer bucket to take food item temperatures. She stated she would take care of it and would talk to the DM. The surveyor asked for the policy on food temperature testing in between food items at that time and it was not provided at the exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped with the accommodation of resident needs and preferences essential to creating an individualized , home like environment in that residents need to call for staff assistance through a communication system that relayed the call directly to a staff member or a centralized staff work area for 2 of 88 residents (Residents #1 and #2) reviewed for resident call systems, in that: The facility failed to ensure Residents' #1's and #2's call lights within reach. This failure could have placed residents at risk of being unable to obtain assistance when needed. The findings included: 1. Record review of Resident #1's face sheet, dated 02/28/23, revealed a [AGE] year-old male with an admission date of 02/23/2023, diagnosed with [Anemia] condition that does not carry enough oxygen to the rest of your body via your blood, [Coronary Arterial Disease] Condition that causes the buildup of plaque. This causes coronary arteries to narrow, limiting blood flow to the heart, and [Hypertension] is when the blood vessels have persistently raised pressure. Review of Resident #1's baseline care plan, dated 2/24/2023, revealed the intervention, Ensure the call light is within reach. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS score of 11, suggesting moderate impairment. Observation on 02/28/23 at 9:30 a.m. revealed the call light for Resident #1 was not within the resident's reach and was on the floor. Observation and interview on 02/28/23 beginning at 9:35 a.m., CNA A confirmed the call light for Resident #1 was not accessible on the floor, and she was the assigned CNA. CNA A stated the resident was at risk of needing something and did not have the means to ask for assistance while sitting in his wheelchair. Interview with Resident on 02/28/2023 at 9:36 a.m., Resident #1 stated, I don't know why they leave my call light so far from me; what if I need to call for help, I will fall trying to get that call light off the floor. Observation and interview on 02/28/2023 beginning at 9:40 a.m., revealed a call light on the floor, not at arm's length, while Resident #1 was in his wheelchair. LVN A confirmed she was the assigned nurse, and the call light was not within reach of Resident #1. LVN A stated she did not know why the call light was on the floor, and the patient risked a fall or could have needed something and did not have a way to ask for assistance. 2. Record review of Resident #2's face sheet, dated 02/28/23, revealed a [AGE] year-old male with an admission date of 2/22/2023, diagnosed with [ Hemiparesis Left Side] condition that is an after-effect of stroke that causes weakness on the left side of your body, [ Right Below the Knee Amputation] Surgical procedure involves removing the foot, ankle joint, distal tibia, and fibula with related soft tissue structures, and [Blind Left Eye] No vision in Left eye. Record review of Resident #2's baseline care plan, dated 2/23/2023, revealed the intervention, Ensure the call light is within reach; the resident is at risk for falls. Record review of Resident #2's admission MDS, dated [DATE], revealed the resident had a blank BIMS score, indicating the resident could not complete the assessment. Observation on 02/28/23 at 9:45 a.m. revealed the call light for Resident #2 was not within the resident's reach, it was on the bedside table. Interview with Resident #2 on 02/28/2023 at 9:36 a.m., Resident #2 stated, The girls were very busy today and forgot to put my call light next to me; if I need help, I will have to yell. Observation and interview on 02/28/23 at 9:50 a.m., CNA B confirmed the call light for Resident #2 was on a bedside table, and she was the assigned CNA. CNA B stated the resident was at risk of needing assistance and did not have a way to ask for assistance while sitting in his wheelchair. Observation and interview on 02/28/2023 beginning at 9:55 a.m. revealed a call light on the nightstand, not at arm's length, while the patient was in his wheelchair. LVN B confirmed she was the assigned nurse, and the call light was not within reach of Resident #2. LVN B stated she did not know why the call light was not within reach of Resident #2 and the resident was at risk of a possible fall or could have needed something and did not have a way to ask for assistance. Interview with the DON on 02/28/2023 at 10:10 a.m., the DON stated residents' call lights should always be within all residents' reach. The DON stated that no resident suffered no harm by not having a call light within reach today but risked needing assistance and not having means of letting anyone know. Record review of the facility's policy titled, Call Light Response, revised 12/2022, revealed, Staff members will ensure call light is within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 5 residents (Resident #1) reviewed for admission physician orders, in that: The facility failed to have a physician order for Resident #1's amputated left great toe and left long toe. This failure could place residents at risk for not receiving appropriate care and treatment services. Findings included: Record review of Resident #1's face sheet, dated 02/28/23, revealed a [AGE] year-old male with an admission date of 02/23/2023, diagnosed with [Anemia] condition that does not carry enough oxygen to the rest of your body via your blood, [Coronary Arterial Disease] Condition that causes the build-up of plaque. This causes coronary arteries to narrow, limiting blood flow to the heart, and [Hypertension] is when the blood vessels have persistently raised pressure. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS score of 11, suggesting moderate impairment. Further review revealed under section other I8000 [additional active diagnosis]-the acquired absence of left great toe and acquired absence of another left toe. Record review of Resident #1's Nursing admission Evaluation Section B, skin integrity, dated 2/23/2023, revealed left toe amputation x 2. Record review of Resident #1's hospital clinicals, dated 2/22/2023, revealed the resident had amputated the left great toe and left long toe on 2/16/2023. Record review of Resident # 1's Treatment record for 2/23 and 3/23 , revealed no orders for wound care for the residnets left great toe and left long toe . Record review of Report [Physican signed to date for review ] 02/23/2023 , revealed no order for wound care for the resdients left great toe and left long toe. Observation on 02/28/2023 at 9:34 a.m. revealed Resident #1's left great toe and left long toe with stitches and granulation tissue present, with no dressing in place. During an interview with Resident # 1, on 2/28/2023 at 9:30 am , Resident # 1 stated he had not received any care for his foot since his admission on [DATE] . During an interview with LVN A on 2/28/2023 at 9:40 a.m., LVN A stated she was the charge nurse for Resident #1. LVN A stated she was unaware Resident #1 had been admitted for multiple toe amputations of the left foot as she did not receive this information in the morning report. LVN A went to Resident #1 room with the surveyor, and LVN A confirmed Resident #1 had a left foot toe and was missing digits present with stitches. LVN A stated she could not find any orders in the electronic medical record to address this issue. Interview with the DON on 0/28/22 at 9:55 a.m., the DON revealed Resident # 1 should have a physician order specifying any care given to the left foot. The DON stated the lack of physician orders to care for Resident #1 could have been detrimental, leading to a possible left foot infection. The DON did not know why this was missed but would get orders from the physician immediately. Record Review of facility policy titled Wound Care Policy and Procedure,dated March 2020, revealed, admission wound assessment and management, . Any wounds assessed will be captured in the point click care nursing evaluation in progress notes within 6 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 5 residents (Resident #1) reviewed for a baseline care plan. The facility failed to ensure that Resident #1's baseline care plan included information related to the resident's diagnosis of amputated the left great toe and left long toe This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings included: Record review of Resident #1's face sheet, dated 02/28/23, revealed a [AGE] year-old male with an admission date of 02/23/2023, diagnosed with [Anemia] condition that does not carry enough oxygen to the rest of your body via your blood, [Coronary Arterial Disease] Condition that causes the build-up of plaque. This causes coronary arteries to narrow, limiting blood flow to the heart, and [Hypertension] is when the blood vessels have persistently raised pressure. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS score of 11, suggesting moderate impairment. Further review revealed under section other I8000 [additional active diagnosis]-the acquired absence of left great toe and acquired absence of another left toe. Record review of Resident #1's Nursing admission Evaluation Section B, skin integrity, dated 2/23/2023, revealed left toe amputation x 2. Record review of Resident #1's hospital clinicals, dated 2/22/2023, revealed the resident had amputated the left great toe and left long toe on 2/16/2023. Record review of Resident's # 1 baseline care plan dated 2/23/2023, revealed no care plan for wound on left great toe and left long great toe . Observation on 02/28/2023 at 9:34 a.m. revealed Resident #1's left great toe and left long toe with stitches and granulation tissue present, with no dressing in place. During an interview with LVN A on 2/28/2023 at 9:40 a.m., LVN A stated she was the charge nurse for Resident #1. LVN A stated she was unaware Resident #1 had been admitted for multiple toe amputations of the left foot as she did not receive this information in the morning report. LVN A went to resident #1 room with the surveyor, and LVN A confirmed Resident #1 had a left foot toe and was missing digits present with stitches. LVN A stated she would call the doctor and get orders and did not know why it was not addressed in the baseline care plan and suggested I speak to the MDS nurse regarding baseline care plans. During a record review and interview regarding confirmation with MDS Coordinator on 02/28/2023 at 10:02 a.m., MDS Coordinator confirmed the diagnosis of amputated left great toe and left long toe were not on the baseline care plan for Resident #1. The MDS Coordinator stated it was his job to complete the baseline care plan. The MDS Coordinator stated an incomplete baseline care plan could negatively impact communication among nursing home staff, leading to unmet patient needs. The MDS Coordinator stated he did not know why baseline care plans were incomplete but would promptly complete them. During an interview and confirmation with the DON on 02/28/2023 at 10:25 a.m., the DON confirmed Resident #1's needs should have been addressed on their baseline care plans. The DON did not know why it was not completed but expected baseline care plans to reflect the patient's requirements to care for the first 48 hours completed by the MDS nurse. The DON stated the lack of a complete baseline care plan risks not having all healthcare team members on the same page with residents leading to possible unmet resident needs. Record review of the facility's policy titled, Care Plan, dated November 2022, revealed, A baseline care plan is developed for each resident upon admission no later than 48 hours of admission, to the facility. The care plan includes minimum heal care information necessary to properly care for a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a Resident needing respiratory care is provided such care consistent with professional standards of practice with a physician's order for oxygen care for 1 of 88 residents (Resident #3) reviewed for respiratory care, in that: The facility did not obtain a Physician's order for the oxygen use that was provided to Resident #3. This failure could place Residents at further risk by not having Physician's orders for the clinical intervention of respiratory care provided. The findings include: Record review of Resident #3's face sheet, dated 3/1/23, revealed the [AGE] year old Resident was admitted to the facility on [DATE] with diagnoses including: gastrointestinal hemorrhage (a bleeding disorder in the digestive tract), urinary tract infection (an infection in a part of the urinary system), and chronic obstructive pulmonary disease-COPD (a condition involving constriction of the airways and difficulty breathing). Record review of Resident #3's care plan, initiated 3/1/23, revealed Resident #3 has altered respiratory status, difficulty breathing, and chronic respiratory failure. Record review of Resident #3's physician order summary, dated 3/1/2023, revealed the [AGE] year-old resident was admitted to the facility on 2//25/23 with diagnoses including: COPD, and a dependence on supplemental oxygen. There was no physician order for the oxygen usage. Observation on 3/1/23 at 12:10 p.m. in the room of Resident #3 noted that Resident #3 was utilizing her oxygen via a nasal canula; the oxygen concentrator was set at a 3 liter flow. During an interview with Resident #3 on 03/1/23 at 3:15 p.m. regarding the oxygen, Resident #3 stated she felt, it helps having it on. Resident #3 stated she used oxygen at home on a 3 liter setting. During an interview with the DON on 03/1/23 at 12:30 p.m., the DON stated Resident #3 did not have a current physician oxygen order. The DON stated the resident's treatment would not be appropriate without having a physician's order for the oxygen use. Record review of the facility's policy on oxygen hygiene, dated November 2021, reavealed, any resident receiving any type of oxygen delivery will have orders in the electronic record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility inaccurately coded a resident assessment for 1 of 1 discharged residents (Resident #99) reviewed for data encoding and transmission in that: Resident #99's Discharge MDS was not coded accurately. This failure affected residents who have been discharged and placed them at risk of not having their assessments transmitted accurately. The findings included : Review of Resident #99's clinical record revealed an admission date of 2/23/2022 with diagnoses that included: fracture of right lower leg (ankle), diabetes (high blood sugar), diabetes foot ulcer with deep tissue damage to left heel (damage to the deeper structures under the skin), diabetic retinopathy with macular edema ,(retinal thickness and damaged blood vessels in the retina), renal dialysis (artificial way of replacing some kidney function), and dysphagia (difficulty swallowing). Review of resident #99's MDS, discharge, return not anticipated/end of PPS Part A stay dated 4/5/2022, section A 1800 was coded 03, acute hospital. Review of Resident #99's Discharge summary, dated [DATE], section A revealed Resident #99 was discharged to home with home health services. Interview conducted on 5/19/2022 at 10:37 a.m. with the CNO, she stated that it is important for the MDS to be coded correctly because the MDS triggers the care plan and assists in determining residents' benefits for discharged , current and future admissions . Interview conducted on 5/20/2022 at 1:24 p.m. with MDS RN, he confirmed that he is responsible for the accuracy of that the MDS. He stated that the MDS dated [DATE] for Resident #99 was coded incorrectly. The MDS coordinator stated that accuracy is important because it drives care, reimbursement

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission for for 8 of 24 residents (#10, #212, #217, #220, #257, #258, #259, #264) reviewed for baseline care plans, in that: 1. Resident #212's baseline care plan did not address Resident #212's fluid restrictions. 2. Resident #217's baseline care plan did not address advance directives-code status. 3. Resident #220's baseline care plan did not address the residents Dementia/Alzheimer's. 4. The facility did not address Residents #10, #257, #258, #259, and #264 code statuses on their baseline care plans. These failures could affect residents who were newly admitted to the facility and could result in them not receiving, continuity of care and communication among nursing home staff to ensure that immediate care needs are met: The findings were: 1. Review of Resident #212's admission record dated 05/20/2022 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included: aftercare following orthopedic surgical amputation (removal of a body part), acquired absence of left toes (removal of toes), diabetes (high blood sugar), hyperkalemia (high potassium in blood), transient ischemic attack( mini brain strokes)( , cerebral infarction (mini stroke), heart failure (congestive heart failure, fluid filled lungs), gangrene (death of body tissue), anemia (low red blood cells), hyperlipidemia ( high cholesterol), atherosclerotic heart disease (buildup of plaque), heart block (abnormal heart rhythm), cardiac pacemaker (device implanted in chest to control heartbeat), atrial fibrillation (heart palpitations), peripheral vascular disease (narrowing of arteries), end stage renal disease (kidney failure) ,and dependence on renal dialysis (removal of waste from the body). Review of Resident #212's clinical record revealed the resident did not have an MDS completed. Review of Resident #212's Physician's order summary dated, 5/18/2022, revealed an order dated 5/1/2022 for controlled carbohydrate diet and fluid restrictions of 1500 cc/per day - record fluid intake every shift, and at every meal, dietary 1140 cc, nursing 300cc. Review of Resident #212's initial nursing care plan completed on admission, 5/1/2022, revealed it did not address Resident 212's dialysis status or fluid restrictions. Review of Resident # 212's baseline care plan dated 5/3/2022 with updates on 5/17/2022 revealed it did not address Resident #212's fluid restrictions. Observation and interview on 5/17/2022 at 9:30 a.m. revealed Resident #212 lying across his bed. Resident #212 stated that he was waiting for his pain medication before he has to go to dialysis. Interview on 5/20/2022 at 10:37 a.m. with the CNO, she stated Resident #212's fluid restrictions which were ordered upon admission should be on his baseline care plan. She stated that it is the charge nurse or admitting nurse to start the baseline care plan and items would be added once additional information is learned about the resident. She further stated that it is her responsible to oversee care plans. She further stated that monitoring of fluid consumption in dialysis residents is important to prevent buildup of fluids between dialysis dates. 2. Record review of Resident# 217's admission record dated 5/20/2022 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of :dehydration (water volume depletion), kidney failure (lose of function of kidney), cyst of kidney (small round oval sacs fluid filled in the kidney), hypokalemia (low potassium), adult failure to thrive (manifestation of combined underlying physical, psychosocial and/or mental health conditions), atrial fibrillation (heart palpitations), autoimmune hepatitis (liver failure), and hypertension (high blood pressure. Review of Resident #217's clinical record revealed the admission MDS and the BIMS score was not completed. Review of Resident #217's physician's order summary dated 5/18/2022 revealed an order written on 4/30/2022 for full code status. Review of Resident #217's baseline care plan initiated on 5/17/2022 did not address Resident #217's advanced directives or code status. Observation and interview with Resident #217 on 5/17/2022 at 10:30 a.m. revealed the resident sitting in his room, the resident denied any complaints currently. 3. Record review of Resident #220's admission record dated 5/20/2022 revealed, an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including: Displaced intertrochanteric fracture of right femur (hip fracture along the thigh), falls, hypothyroidism (decrease in thyroid hormone), dementia (brain disease that causes long term decrease in ability to think and remember), Alzheimer's disease (cognition and functional decline), hypertension (high blood pressure), and heart failure (inability to pump enough blood and oxygen to meet the body's needs). Review of Resident #220's clinical record revealed the admission MDS with the BIMS score was in progress. Review of Resident #220's baseline care plan initiated on 5/15/2022 did not address Resident #220's Dementia/Alzheimer's. Observation of Resident #220 on 5/17/2022 at 11:00 a.m. revealed the resident was sitting beside his bed. Resident #220 appeared confused and was not responsive to questions. Interview on 5/20/2022 at 10:37 a.m. with the CNO, she stated it would be important to identify dementia and Alzheimer's on the admission care plan and it should be on the baseline care plan to ensure continuity of care and that required care was being given. 4. Record review of Resident #10's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure (usual exchange between oxygen and carbon dioxide (CO2) in the lungs does not occur), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), anxiety disorder (a persistent feeling of anxiety or dread), major depressive disorder (persistently depressed mood and long-term loss of pleasure or interest in life), and altered mental status. Record review of Resident #10's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #10's EHR revealed no code status entered on the baseline care plan, dated 05/12/2022. Record review of Resident #257's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), cardiac pacemaker (small device placed in chest to help control heartbeat) and dementia. Record review of Resident #257's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #257's EHR revealed no code status entered on the baseline care plan, dated 05/15/2022. During an interview on 05/20/22 at 10:10 a.m., Resident #257's MPOA stated the resident was a DNR, and she had the DNR form at home. She further stated the facility had not asked for her to bring it to the facility and only asked if she had one for the resident. During an interview on 05/19/22 at 4:02 p.m., LVN E stated a resident's code status was supposed to show up right under the resident's name in the EHR. She further stated the code status was also under the order, which is how it comes up as a banner under their name. LVN E stated if there was no order and no code status in the banner under the name then the resident is automatically considered FC. She also said if resident reflected as a DNR but there was no DNR in the system then that resident was also considered FC. During an interview on 05/20/22 at 11:02 a.m., the CNO stated staff would contact the SW to make sure she gave the okay for a resident to be a DNR if there was no DNR in the resident's EHR. The CNO stated Resident #257's DNR was also, possibly, in the to be scanned box but that the SW should have a copy of it too. The CNO further stated the DNR was supposed be uploaded as soon as it was received and that Resident #257's EHR was supposed to stay FC until the DNR was uploaded into his EHR. The CNO stated the potential harm to this resident was his wishes were not followed. During an interview on 05/20/22 at 12:55 P.M., the GM stated Resident #257's order was changed to FC because there was not a signed DNR in house. She further stated his family was re-asked to bring the DNR to the facility and had yet to bring it. Record review of Resident #258's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), altered mental status, and part of right femur fracture. Record review of Resident #258's MDS' revealed he did not have a completed MDS in her EHR. Record review of Resident #258's EHR revealed no code status entered on the baseline care plan. Record review of Resident #259's face sheet, dated 05/20/2022, revealed the resident was admitted on [DATE] with diagnoses that included: dependence on supplemental oxygen, pulmonary fibrosis (thickening or scarring of lung tissue), rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), major depressive disorder, and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #259's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #259's EHR revealed no code status entered on the baseline care plan, dated 05/06/2022. Record review of Resident #264's face sheet, dated 05/20/2022, revealed the resident was admitted on [DATE] with diagnoses that included: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), anxiety disorder, major depressive disorder, and seizures. Record review of Resident #264's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #264's EHR revealed no code status entered on the baseline care plan, dated 05/03/2022. During an interview on 05/20/2022 at 10:33 with the CNO, she stated every resident should have a baseline care plan completed within 48 hours of admission at that it should cover information that is critical to the residents care. She stated that fluid restrictions, dementia care and code status are important areas of the care plan. She further stated the care plans were important to assure proper care was provided and the care plan provides contnuity of care. Review of the facility policy and procedure titled Care Plan - Resident, dated November/2018, revealed, #1 a baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission, to the facility. This care plan includes minimum health care information necessary to properly care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan for 7 of 9 (Resident #4, #12, #21, #86, #198, #216 and #259) residents who received oxygen in that: 1. The facility did not ensure Resident #4's oxygen tubing was dated and bagged when not in use. 2. The facility did not ensure Resident #12's oxygen tubing was dated, bagged when not in use and that there were physician's orders for the use of oxygen. 3. The facility did not ensure Resident # 21's oxygen tubing was dated, bagged when not in use and that there were physician's orders for the use of oxygen. 4. The facility did not ensure Resident #86's oxygen tubing was dated and bagged when not in use. 5. Resident #198 did not have signage on room door, oxygen in use. 6. Resident #216 did not have signage on room door, oxygen in use. 7. The facility did not ensure Resident 259's oxygen filter was dust free. These failures could affect all residents on oxygen and could result in respiratory compromise and/or hypoxia (deficiency in the amount of oxygen reaching the tissues). The findings were: 1. Record review of Resident #4's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility 05/12/2022 with diagnoses that included: chronic obstructive pulmonary diseases (group of diseases that cause airflow blockage and breathing-related problems) with (acute) lower respiratory infection, encephalopathy (damage or disease that affects the brain), generalized anxiety (a feeling of worry, nervousness, or unease) disorder, hypertension (high blood pressure), and systolic (congestive) heart failure (when the heart does not pump blood effectively). Record review of Resident #4's EHR revealed that MDS was not due for completion at the time. Record review of Resident #4's care plan initiated on 05/18/2022 revealed a care plan for Altered respiratory status/difficulty breathing related to COPD and requires use of oxygen Change O2 and nebulizer tubing weekly and as needed, keep oxygen line free of moisture. Record review of Resident #4's physician order summary report, dated, 05/18/2022, revealed an order for Change O2 mask or nasal cannula and tubing weekly every night shift every Tues, Sun. with a start date of 05/17/2022 and no end date. Observation on 05/17/2022 at 10:30 a.m. Resident #4's tubing and nasal cannula were hung over the oxygen concentrator with no date on the tubing. Observation and interview on 05/18/2022 at 12:27 p.m. revealed Resident #4's oxygen tubing and nasal cannula were observed hanging over the top of the lamp at bedside attached to the oxygen concentrator. Resident #4's family member stated the oxygen was discontinued a couple days ago, and Resident #4 doesn't use it. He further stated he did not know if the tubing had been changed during her stay. During an interview on 05/18/2022 at 12:40 p.m. RN A stated Resident 4 had been winged during the day, so her oxygen was only PRN and that Resident #4 usually used it at night. RN A further stated the nasal cannula and tubing should have been bagged when Resident #4 was not using it. RN A then stated the bag and the tubing should have been labeled with the date it had been changed and stated she could not find the date on Resident #4's tubing, therefore she was not able to tell when tubing had been changed and further stated the nasal cannula and tubing are supposed to be changed on Sundays. 2. Record review of Resident #12's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility 05/04/2022 with diagnoses that included: acute respiratory failure with hypoxia (don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), disorientation, altered mental status, pneumonitis due to inhalation of other solids and liquids (occurs when an irritating substance causes the tiny air sacs (alveoli) in your lungs to become inflamed), dysphagia (difficulty swallowing), dementia, hypertension (high blood pressure), and pulmonary hypertension (when the pressure in the blood vessels leading from the heart to the lungs is too high). Record review of Resident #12's physician's order summary dated 05/18/2022 revealed no orders for oxygen use nor the care of nasal cannula or oxygen tubing. Record review of Resident #12's EHR revealed that MDS was not due for completion at the time. During an observation and interview on 05/17/2022 at 9:43 a.m. revealed Resident #12's nasal cannula and tubing were hanging over the lamp on the bedside table while Resident #12 was sitting in her wheelchair next to the bed. A family member of Resident #12 stated Resident #12 had just been given a bath and her oxygen was not put back on. Observation revealed oxygen tubing was not dated, and Resident #12's family member further stated she had never seen anyone change Resident #12's nasal cannula or oxygen tubing. Observation on 05/18/2022 at 12:31 p.m. revealed Resident #12 sitting in room in her room eating her lunch and the oxygen concentrator was off. The nasal cannula and tubing were not dated and were lying over the top of the concentrator. During an interview on 05/18/2022 at 12:45 p.m. RN A stated Resident #12's oxygen tubing was not dated and could not tell when it had been changed. RN A further stated she believed Resident #12 was being winged off her oxygen. 3. Record review of Resident #21's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: low back pain, repeated falls, weakness, elevated white blood cell count, alcohol use unspecified with unspecified alcohol induced disorder, syncope (temporary loss of consciousness caused by a fall in blood pressure) and collapse, obstructive sleep apnea (occurs when the muscles in the back of your throat relax too much to allow normal breathing) (adult), hypertension (high blood pressure), and chronic diastolic (congestive) heart failure (occurs if the left ventricle muscle becomes stiff or thickened). Record review of Resident #21's physician order summary dated 05/18/2022 revealed no orders for oxygen use nor the care of nasal cannula or oxygen tubing. Record review of Resident #21's EHR revealed that MDS was not due for completion at the time. During an observation and interview on 05/17/2022 at 11:52 a.m. observed oxygen concentrator present in the room of Resident #21 with tubing not dated nor bagged while not in use. Resident #21 stated he was taken off his oxygen the day before and it was no longer needed. Resident #21 further stated that he was not sure if the staff had changed nasal cannula tubing. During an interview on 05/18/2022 at 12:40 p.m. RN A stated Resident #21's tubing was not dated and should have been. RN A further stated Resident #21 was being winged off his oxygen and that he had not used it lately. 4. Record review of Resident #86's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic diastolic (congestive) heart failure (occurs if the left ventricle muscle becomes stiff or thickened), chronic atrial fibrillation unspecified (heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly lasting longer than a week), hypertension (high blood pressure), pulmonary hypertension (when the pressure in the blood vessels leading from the heart to the lungs is too high), interstitial pulmonary disease (a large group of disorders, most of which cause progressive scarring of lung tissue), displaced intertrochanteric fracture of right femur, encounter for closed fracture with routine healing, acute kidney failure unspecified (sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), and hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream). Record review of Resident #86's Admission/5-day MDS, dated [DATE], revealed special treatments prior to admission of receiving oxygen however, while a resident not receiving oxygen treatments. Record review of Resident #86's physician order summary dated 05/18/2022 revealed orders to monitor O2 saturation every shift and monitor O2 (oxygen) saturation as needed for S/S (signs and symptoms) of low O2 Sats. Physician order summary further revealed no orders for oxygen use nor the care of nasal cannula or oxygen tubing. Record review of Resident #'86's care plan initiated on 05/17/2022 revealed a care plan for Altered respiratory status/difficulty breathing related to interstitial pulmonary disease, uses O2 1lpm (oxygen flow rate 1liter per minute) per NC (nasal cannula). Record review of Resident #86's admission Nursing Evaluation dated 04/22/2022 revealed oxygen therapy being used while a resident at a rate of 1 liter per minute via nasal cannula. During observation and interview on 05/17/2022 at 12:32 p.m. revealed Resident #86 had oxygen and Resident #86 stated she had anxiety attacks. Further observed an oxygen concentrator at bed side with the tubing not dated. Resident #86 further stated that she had not seen the facility staff change the tubing and had no idea when they did it. During observation and interview on 05/18/2022 at 12:40 p.m. revealed Resident #86 resting in bed with family at her bedside. The oxygen concentrator had been removed from Resident #86's room however, Resident #86 stated she needed it for her anxiety at times. During an interview on 05/20/2022 at 10:35 a.m. the CNO stated the oxygen tubing was changed once a week on Sundays at night by the nurse and that when it was not being worn the nasal cannula/oxygen tubing should be placed in a bag. The CNO further stated orders are obtained for winging residents off oxygen and if the tubing is not changed a resident could risk getting an infection. The CNO stated the oxygen tubing should be labeled with the date that it was changed and when oxygen is no longer necessary the concentrator would be removed from the room, placed at the nurses' station so it could be cleaned for next resident use. During an interview on 05/20/2022 at 2:27 p.m. the GM stated the oxygen tubing was usually stored in a zip-lock bag in the room when not in use. The GM further stated that she would need to check the policy regarding when tubing should be changed, but the tubing should be dated when changed. The GM stated by not cleaning or changing the tubing could allow germs to go through the tubing to the nasal passages and lungs. The GM stated residents should have orders for the tubing changes with how much they are on and how often. 5. Record Review of Resident # 198's admission record dated 5/20/2022 revealed an [AGE] year old female, admitted to the facility on [DATE] with admitting diagnoses that included: Respiratory failure with hypercapnia (failure of lungs to remove carbon dioxide), hypoxemia (low level of oxygen in blood), chronic obstructive pulmonary disorder (bronchitis), pneumonia (infection of air sacs in one or both lungs), cellulitis of abdominal wall (bacterial infection of skin), gastrostomy (artificial opening into the stomach for nutritional support), gastrostomy ( tube in stomach)infection, dysphagia,(difficulty swallowing) alopecia areata (patchy hair loss), dependence on supplemental oxygen, hypothyroidism (decreased production of thyroid hormone), glaucoma (high pressure in eyes that can lead to blindness), emphysema (lung disease, destruction and dilatation of the alveoli), gastro-esophageal reflux disease (acid reflux), and osteoporosis (weakened bone strength). Record review of Resident #198's physician's order summary dated 5/17/2022 revealed an order for oxygen at 3 liters minute every shift for dyspnea (shortness of breath). Observation of Resident #198 on 5/17/2022 at 11:05 a.m. revealed Resident #198 resting in bed with nasal oxygen cannula infusing from wall monitored gases, set at 3 liters per minute. Interview conducted with LVN A on 5/17/2022 at 11:10 a.m., she stated Resident #198 required continuous oxygen and that the door should be marked with a sign that reflected oxygen in use. She further stated the signage is important in case of a fire. She stated that the nurse that placed the oxygen on the resident should have placed the signage for oxygen in use and that every nurse or therapist going in and out of the room should have noticed that there was not a sign and corrected the issue. 6. Record Review of Resident #216's admission record dated, 5/20/2022 revealed a [AGE] year old female, admitted to the facility on [DATE] with admitting diagnoses that included: urinary tract infection, hydronephrosis (urine accumulation that causes swelling of kidney)with renal and ureteral calculous obstruction(kidney stone), calculus of ureter(stone in ureter), extended spectrum beta-lactamase (ESBL)(enzyme in bacteria that makes infections harder to treat with antibiotics),Escherichia coli(E-Coli)(Bacterium), hypothyroidism( decreased production of thyroid hormones), atherosclerotic heart disease(Plague buildup in the arteries), chronic obstructive pulmonary disease( inflammation that causes obstructed airflow from lungs) , asthma(narrowing of the airways in the lungs), hypertension(high blood pressure), congestive heart failure(progressive heart disease that affects pumping action of heart muscle). Record Review of Resident #216's Physician's order summary dated 5/17/2022 revealed an order for oxygen at 3 liters minute every shift for dyspnea (shortness of breath) and a full code status. Observation of Resident #216 on 5/17/2022 at 9:25 a.m. revealed the resident was lying in bed with oxygen infusing via nasal cannula at 3 liters per minute. Interview conducted with CMA A on 5/17/2022 at 9:30 a.m., she stated Resident #216 required continuous oxygen and every room where oxygen was in use should have a sign reflecting that oxygen was in use. She further stated it was important in case of an emergency. Interview conducted with the CNO on 5/20/2022 at 10:37 a.m., she stated that every door should be marked with an, oxygen in use signage, if the resident is receiving oxygen to where nurses are aware that the resident has oxygen and will require more frequent assessment to ensure that there is no labored breathing. She stated that placing the appropriate signage is a dual responsibility between the nurses and respiratory therapist, but the ultimate responsibility lies on the Charge Nurse. Interview conducted with the GM on 5/20/2022 at 2:30 p.m., she stated if a resident is on oxygen the door should be marked that oxygen is in use to ensure safety. She further stated the signage alerts staff in case of a power failure or fire which residents should be checked for the red plugs. 7. Record review of Resident #259's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dependence on supplemental oxygen, pulmonary fibrosis (thickening or scarring of lung tissue), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #259's MDS' revealed he did not have a completed MDS in his EHR. During an observation and interview on 05/17/22 at 11:36 a.m., CMA B stated, Yes, it is very dirty while he looked at the back of the oxygen concentrator and observed dust where the filter was located. CMA B also stated nursing was responsible for Resident #259's oxygen concentrator. CMA B further stated the potential harm to the resident was respiratory issues and it was a fire hazard. During an interview on 05/17/22 at 11:59 a.m., RN B, stated he did not know how often oxygen concentrators were checked for dust residue. During an interview on 05/20/22 at 10:53 a.m., the CNO, stated oxygen tubing was supposed to be changed out once a week on Sunday's. She further stated the charge nurse scheduled on Sunday's was responsible for changing out the water on the concentrator and changing out the tubing. The CNO stated residents were supposed to have an order for oxygen use that specified how many liters and how often that resident was on oxygen. The CNO also stated all residents on oxygen were supposed to have an oxygen sign outside their door. The CNO then stated there was a company on contract that was responsible for coming in every so often which they performed maintenance checks on the concentrators, and that included making sure the concentrator was dust free. The CNO stated the potential harm to residents, with having dust on a concentrator, was the resident not getting the adequate amount of oxygen. During an interview on 05/20/22 at 02:31 p.m., the GM stated she was not sure of the facility's policy regarding how often staff were to change out the tubing for oxygen. The GM also stated all nasal cannulas were supposed to be placed in a zip lock bag when it was not in use and the tubing was also supposed to be dated when it was changed out. The GM further stated there were supposed to be orders for any resident on oxygen which reflected how many liters they were on and how often. The GM then stated facility has a contract with a company that was responsible for coming out to ensure oxygen concentrators were dust free. The GM also stated there was supposed to be oxygen signs on a resident's doorway when they are oxygen. She further stated the potential harm to residents, with concentrators having dust residue, was germs and bacteria traveling back to the resident's nasal passage and lungs. Record review of AGREEMENT FOR RESPIRATORY CARE CONSULTING SERVICES, EQUIPMENT AND SUPPLIES, provided by the facility, signed 02/28/2022, which reflected [ .] 3. Services. Services, Equipment and supplies shall be provided only at the request of The Facility and under the direction of the The Facility general manager or supervisor and PEL/VIP Practitioners shall abide by and be subject to all of The Facility policies, procedures, rules and regulations while performing services for The Facility. Record review of the facility policy, Door Signs, dated November/2018, revealed Guideline: 1. Residents who are admitted on oxygen or isolation will have orders recorded in the resident's chart. 2. Oxygen signs will be placed outside of door - for both concentrators or liquid oxygen. Record review of facility policy, O2 Hygiene, dated November/2018, revealed Policy: 1. Any resident or guest receiving any type of oxygen will have orders in the electronic medical record, including amount of :L/min. Examples of oxygen delivery can include oxygen via a nasal cannula, nebulizer treatment, CPAP/Bipap, and trilogy machines. 3. Residents or guests will have their oxygen delivery devices and tubing properly stored when not in use. 3. Tubing will be changed and/or cleaned in accordance with physician orders to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were assessed, and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 21 of 24 residents (Residents # 4, #10, #12, # 21, #86, #89, #91, #95, #150, #158, #161, #166, #197, #198, #214, #215, #216, #218, #220, #225, #257) reviewed for bedrails in that: The facility did not assess or get consent for Residents #4, #10, #12, #21, #86, #89, #91, #95, #150, #158, #161, #166, #197, #198, #214, #215, #216, #218, #220, #225 and #257 for the use of bedrails. These failures could put the residents at risk for potential injuries. The findings were: 1. Record review of Resident #4's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary diseases (group of diseases that cause airflow blockage and breathing-related problems) with (acute) lower respiratory infection, encephalopathy (damage or disease that affects the brain), generalized anxiety disorder, hypertension (high blood pressure), and systolic (congestive) heart failure (when the heart does not pump blood effectively). Record review of Resident #4's EHR revealed MDS was not due for completion at the time. Record review of Resident #4's EHR revealed no bedrail assessment or bedrail consent. During observation and interview on 05/20/2022 at 9:10 a.m. revealed Resident #4 was observed with quarter rails to her bed on both sides of the top of the bed. Resident #4 stated that she used the rails to hold when she would get up from the bed. 2. Record review of Resident #10's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure (usual exchange between oxygen and carbon dioxide (CO2) in the lungs does not occur), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), anxiety disorder (a persistent feeling of anxiety or dread), major depressive disorder (persistently depressed mood and long-term loss of pleasure or interest in life), and altered mental status. Record review of Resident #10's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #10's EHR revealed no bedrail assessment or bedrail consent. During an observation on 05/18/22 at 12:10 p.m., revealed Resident #10 was lying asleep in his bed and also had quarter rails, on both sided of the bed, in the up position. 3. Record review of Resident #12's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure with hypoxia (don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), disorientation, altered mental status, pneumonitis due to inhalation of other solids and liquids (occurs when an irritating substance causes the tiny air sacs (alveoli) in your lungs to become inflamed), dysphagia (difficulty swallowing), dementia, hypertension (high blood pressure), and pulmonary hypertension (when the pressure in the blood vessels leading from the heart to the lungs is too high). Record review of Resident #12's EHR revealed MDS was not due for completion at the time. Record review of Resident #12's EHR revealed no bedrail assessment or bedrail consent. During observation and interview on 05/17/2022 at 9:43 a.m. revealed Resident #12 was sitting in her wheelchair at her bedside with 2 quarter side rails in the up position on the bed. Resident #12 stated the side rails helped her when she turned or when she was getting up. 4. Record review of Resident #21's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: low back pain, repeated falls, weakness, elevated white blood cell count, alcohol use unspecified with unspecified alcohol induced disorder, syncope (temporary loss of consciousness caused by a fall in blood pressure) and collapse, obstructive sleep apnea (occurs when the muscles in the back of your throat relax too much to allow normal breathing) (adult), hypertension (high blood pressure), and chronic diastolic (congestive) heart failure (occurs if the left ventricle muscle becomes stiff or thickened). Record review of Resident #21's EHR revealed MDS was not due for completion at the time. Record review of Resident #21's EHR revealed no bedrail assessment or bedrail consent. During observation and interview on 05/18/2022 at 12:40 p.m. revealed Resident #21 sitting in his wheelchair at bedside watching television with quarter rails to both sides of the head of his bed. Resident #21 stated he used them to position while he was in the bed. 5. Record review of Resident #86's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic diastolic (congestive) heart failure (occurs if the left ventricle muscle becomes stiff or thickened), chronic atrial fibrillation unspecified (heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly lasting longer than a week), hypertension (high blood pressure), pulmonary hypertension (when the pressure in the blood vessels leading from the heart to the lungs is too high), interstitial pulmonary disease (a large group of disorders, most of which cause progressive scarring of lung tissue), displaced intertrochanteric fracture of right femur, encounter for closed fracture with routine healing, acute kidney failure unspecified (sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), and hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream). Record review of Resident #86's Admission/5-day MDS, dated [DATE], revealed the resident required extensive assistance (resident involved in activity: staff provide weight-bearing support) by two-person physical assist for transfers and bed mobility. Record review of Resident #86's EHR revealed no bedrail assessment or bedrail consent. During observation on 05/20/22 at 9:13 a.m. revealed Resident #86 with quarter rails to both sides of the head of her bed . 6. Record review of Resident #89's face sheet, dated 05/20/2022, revealed the resident was admitted on [DATE] with diagnoses that included: spinal stenosis (narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine), acute kidney failure (kidneys suddenly become unable to filter waste products from your blood), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), seizures, and quadriplegia. Record review of Resident #89's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #89's EHR revealed no bedrail assessment or bedrail consent. 7. Record review of Resident #91's face sheet, dated 05/20/2022, revealed the resident was admitted [DATE] with diagnoses that included: infection and inflammatory reaction due to internal left hip prosthesis, presences of left artificial hip joint, methicillin resistant staphylococcus aureus infection as the cause of diseases, hypokalemia (lower than normal potassium level in your bloodstream), acute posthemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating hemoglobin), obstructive sleep apnea (adult) (when the muscles in the back of your throat relax too much to allow normal breathing), hyperlipidemia (your blood has too many lipids (fats) in it), major depressive disorder, and hypertension (high blood pressure). Record review of Resident #91's 5-day MDS, dated [DATE], revealed the resident required extensive assistance (resident involved in activity: staff provide weight-bearing support) by two-person physical assist for transfers and bed mobility. Record review of Resident #91's EHR revealed no bedrail assessment or bedrail consent. Observation on 05/17/2022 at 2:14 p.m. revealed Resident #91 was sitting in his wheelchair at bedside with quarter rails to the head of his bed on both sides. 8. Record review of Resident # 95's admission record dated 5/20/2022 revealed, a [AGE] year old female, admitted on [DATE] with diagnoses that included: sepsis( infection of the blood stream), cellulitis of left and right lower limb(infection of skin), non-pressure chronic ulcer of right and left leg(skin wounds), urinary tract infection, acute kidney failure, diabetes(high blood sugar), hyperlipidemia(high cholesterol), hypertension(high blood pressure), atrial fibrillation(heart palpitations), atrial flutter(cardiac arrythmia), peripheral vascular disease( narrowing of arteries reducing blood flow), venous insufficiency( high blood pressure in the legs), lymphedema( tissue swelling caused by accumulation of protein rich fluid), major depressive disorder and anxiety. Record review on 5/17/2022 at 2:00 p.m. revealed that no MDS BIMS score was due for completion at this time. Record review of Resident #95's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident # 95 on 5/17/2022 at 12:30 p.m. lying in bed with ¼ side rails in up position bilaterally. 9. Record review of Resident #150's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: displaced intertrochanteric fracture of left femur subsequent, encounter for closed fracture with routine healing, unspecified fall, malignant neoplasm of unspecified part of right bronchus of lung, chronic atrial fibrillation (heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly lasting longer than a week), chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), hypertension (high blood pressure) and tobacco use. Record review of Resident #150's EHR revealed MDS was not due for completion at the time. Record review of Resident #150's EHR revealed no bedrail assessment or bedrail consent. During observation on 05/16/2022 at 9:43 a.m. revealed Resident #150 lying in his bed with both quarter rails up at the head of his bed with head of bed elevated. 10. Record review of Resident #158's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: infection and inflammatory reaction due to internal right knee prosthesis, arthritis due to other bacteria right knee, long term use of antibiotics, acute posthemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating hemoglobin), muscle wasting and atrophy, hyperlipidemia (your blood has too many lipids (fats) in it), major depressive disorder, insomnia, bipolar disorder, hypertension (high blood pressure), and unspecified osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time). Record review of Resident #158's 5-day MDS, dated [DATE], revealed the resident required extensive assistance (resident involved in activity: staff provide weight-bearing support) by two-person physical assist for transfers and bed mobility. Record review of Resident #158's EHR revealed no bedrail assessment or bedrail consent. During observation on 05/19/2022 at 2:16 p.m. revealed Resident #158 with quarter rails to the head of her bed both up. 11. Record review of Resident #161's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (common after-effect of stroke that causes weakness on one side of the body), encephalopathy (damage or disease that affects the brain), aphasia (condition that affects your ability to communicate), hypertension (high blood pressure), and hypokalemia (lower than normal potassium level in your bloodstream). Record review of Resident #161's EHR revealed MDS was not due for completion at the time. Record review of Resident #161's EHR revealed no bedrail assessment or bedrail consent. During observation and interview on 05/18/22 2:20 p.m. Resident #161 observed sitting at bedside in wheelchair waiting for staff to assist her back to bed with quarter rails to head of the bed. Resident #161 stated that she used them for help during care in bed, positioning and getting out of bed. 12. Record review of Resident #166 face sheet, dated 05/20/2022, revealed the resident was admitted [DATE] with diagnoses that include: chronic systolic (congestive) heart failure, syncope and collapse, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension (high blood pressure), weakness, hypothyroidism, and presence of automatic (implantable) cardiac defibrillator. Record review of Resident #166's EHR revealed MDS was not due for completion at the time. Record review of Resident #166's EHR revealed no bedrail assessment or bedrail consent. During observation and interview on 05/17/2022 at 2:52 p.m. revealed Resident #166 sitting in her bed with both quarter rails up at the head of her bed. Resident #166 stated she used them to pull up in her bed and when she was getting out of bed for leverage. 13. Review of Resident # 197's admission record dated 5/20/2022 revealed , a [AGE] year old male, admitted on [DATE] with admitting diagnosis that included: appendicitis(inflammation of the appendix), sepsis(infection in blood stream), diabetes( high blood sugar), disorder of phosphorous metabolism( abnormal serum phosphate levels in the blood), acute kidney failure, chronic mastoiditis ( infection of middle ear), ear, hypothyroidism( decreased production of thyroid hormone), and hypertension( high blood pressure). Review of Resident #197's clinical record revealed that the admission MDS with BIMS score was not due for completion. Record review of Resident #197's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident #197 on 5/17/2022 at 12:30 p.m. lying in bed with ¼ side rails in up position bilaterally. 14. Record Review of Resident #198's admission record dated 5/20/2022 revealed, [AGE] year old female, admitted on [DATE] with admitting diagnoses that included: Respiratory failure with hypercapnia( failure of lungs to remove carbon dioxide), hypoxemia( low level of oxygen in blood), chronic obstructive pulmonary disorder( bronchitis), pneumonia( infection of air sacs in one or both lungs), cellulitis of abdominal wall(bacterial infection of skin), gastrostomy(artificial opening into the stomach for nutritional support) , gastrostomy infection, dysphagia,(difficulty swallowing) alopecia areata(patchy hair loss), dependence on supplemental oxygen, hypothyroidism(decreased production of thyroid hormone), glaucoma( high pressure in eyes that can lead to blindness), emphysema(lung disease, destruction and dilatation of the alveoli), gastro-esophageal reflux disease(acid reflux), osteoporosis(weakened bone strength). Record Review of Resident #198's BIMS MDS 3.0 dated 5/12/2022 revealed a score of 15, cognitively intact. Record review of Resident #198's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident # 198 on 5/17/2022 at 11:05 a.m. revealed Resident #198 resting in bed with nasal oxygen cannula infusing from wall monitored gases, set at 3 liters per minute. Bilateral ¼ side rails in the up position. 15. Review of Resident # 214's admission record dated 5/20/2022 revealed, a [AGE] year old female, was admitted on [DATE] with diagnosis that included: urinary tract infection, hypoxemia(low oxygen in blood), altered mental status(disruption in how your brain works), sepsis(microbial invasion of the body), acute kidney failure( kidney failure), hyperosmolality(occurs in dehydration), hypernatremia(high sodium concentrations in the blood, pulmonary fibrosis(scarring in the lungs), gout(arthritis), hypertension( high blood pressure, congestive heart failure( fluid buildup), pneumonia, systemic lupus erythematosus(scarring in the lungs), systemic sclerosis(hardening/tightening of skin and connective tissue), viral hepatitis(liver infection), anemia(deficiency of red blood cells), immunodeficiency( inability to produce a normal compliment of antibodies), chronic obstructive pulmonary disease(Chronic inflammatory lung disease), scleroderma( hardening and tightening of patches of skin), chronic kidney disease, stage 4( loss of 85 to 90 percent of kidney function), and atherosclerosis(narrowed and hardened arteries). Record review of Resident 214's admission BIMS dated 5/7/2022 revealed a score of 6, severe cognitive impairment. Record review of Resident #214's EHR revealed no bedrail assessment or bedrail consent. Observation on 5/17/2022 at 10:00 A.M. of Resident #214 resting in bed with ¼ bilateral side rails in the up position. 16. Review of Resident #215's admission record dated 5/20/2022 revealed, [AGE] year-old female, admitted [DATE] with diagnoses that included: congestive heart failure(heart failure in which the heart is unable to maintain adequate circulation of blood), bradycardia(slow heart rate), pulmonary hypertension( high blood pressure affecting the lungs and the right side of the heart), mitral valve insufficiency(mitral valve in the heart does not close properly), tricuspid valve insufficiency(Valve in heat that does not close tightly enough to prevent leakage ), atherosclerotic heart disease( plague buildup), cardiac defibrillator( implanted cardioverter defibrillator), diabetes(high blood sugar), hyperlipidemia( high cholesterol), and gout(arthritis). Review of BIMS MDS 3.0 assessment dated [DATE] revealed a score of 15, cognitively intact. Record review of Resident #215's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident #215, on the hot zone. Resident #215 is on transmission-based precautions due to a positive COVID 19 test. Resting in bed with ¼ bilateral side rails in the up position. 17. Record Review of Resident #216's admission record dated, 5/20/2022 revealed, [AGE] year old female, admitted on [DATE] with admitting diagnoses that included: urinary tract infection, hydronephrosis (urine accumulation that causes swelling of kidney)with renal and ureteral calculous obstruction(kidney stone), calculus of ureter(stone in ureter), extended spectrum beta-lactamase (ESBL)(enzyme in bacteria that makes infections harder to treat with antibiotics),Escherichia coli(E-Coli)(Bacterium), hypothyroidism( decreased production of thyroid hormones), atherosclerotic heart disease(Plague buildup in the arteries), chronic obstructive pulmonary disease( inflammation that causes obstructed airflow from lungs) , asthma(narrowing of the airways in the lungs), hypertension(high blood pressure), congestive heart failure(progressive heart disease that affects pumping action of heart muscle). Record Review of Resident #216's clinical record revealed that the admission MDS with BIMS score was not due for completion. Record review of Resident #216's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident #216 on 5/17/2022 at 9:25 a.m. lying in bed with oxygen infusing via nasal cannula at 3 liters per minute. ¼ bilateral side rails in the up position. 18. Review of Resident #218's admission record dated 5/20/2022 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included: displaced fracture of lower end of right humerus(upper arm bone), fracture of pubis(pelvic bone), repeated falls, hypokalemia(low potassium), major depressive disorder, hypothyroidism( decrease in thyroid hormones), aortic valve insufficiency( heart valve disease where the aortic valve does not adequately control flow of blood from the left ventricle into the aorta), anxiety disorder, Gastro-Esophageal reflux disease(heartburn), atrial fibrillation(heart palpations). Record review of Resident #218's BIMS summary dated 5/3/2022 revealed a score of 15, cognitively intact. Record review of Resident #218's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident 218, on the hot zone. Resident 218 is on transmission-based precautions due to a positive COVID 19 test. Lying in bed with 1/4 side rails in the up position with the head of bed elevated. 19. Record review of Resident #220's admission record dated 5/20/2022 revealed, a [AGE] year old male, admitted on [DATE] with diagnoses including: Displaced intertrochanteric fracture of right femur) hip fracture along the thigh), falls, hypothyroidism (decrease in thyroid hormone), dementia (brain disease that causes long term decrease in ability to think and remember), Alzheimer's (cognition and functional decline), hypertension (high blood pressure), and heart failure (inability to pump enough blood and oxygen to meet the body's needs). Review of Resident # 220's clinical record revealed that admission MDS with BIMS score was in progress. Record review of Resident #220's EHR revealed no bedrail assessment or bedrail consent. Observation of Resident #220 on 5/17/2022 at 11:00 a.m. sitting beside bed. Bed equipped with ¼ bilateral side rails. 20. Record review of Resident #255's face sheet, dated 05/20/2022, revealed the resident was admitted on [DATE] with diagnoses that included: sepsis (body's extreme response to an infection), acute kidney failure (kidneys suddenly become unable to filter waste products from your blood) , and osteoarthritis (degeneration of joint cartilage and the underlying bone). Record review of Resident #255's MDS' revealed he did not have a completed MDS. Record review of Resident #255's EHR revealed no bedrail assessment or bedrail consent. 21. Record review of Resident #257's face sheet, dated 05/20/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), cardiac pacemaker (small device placed in chest to help control heartbeat) and dementia. Record review of Resident #257's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #257's EHR revealed no bedrail assessment or bedrail consent. During an observation and interview on 05/20/22 at 10:10 a.m., Resident #257's FPOA stated he had not seen his father use the quarter rails. The FPOA further stated the facility had not asked for consent to use the quarter rails. Further observation revealed quarter rails on both sides of the bed. During interview on 05/19/2022 at 4:05 p.m. LVN F stated because of the size of the side rails they did not have to have a consent and further stated he thought it was in the facility policy. During interview on 05/20/2022 at 10:35 a.m. the CNO stated the facility had never done evaluations or consents for side rails ever since the facility had opened. The CNO further stated they had small quarter rails that were used for positioning, males used to hang the urinals on to make it easy to reach and they were used for transferring support. During an interview on 05/20/2022 at 2:27 p.m. the GM stated it was determined they did not need the evaluation or consent due to the side rails being an enabler and only quarter rails. The GM further stated that the other facilities in the company also did not do evaluations or get consents. Review of the policy titled, Side Rails, dated November 2018 .#2 revealed, Quarter side rails, enabler bar, and/or grab bar type devices are used as positioning device and for patient mobility while in bed. They are also used for transferring and repositioning. They are not considered a restraint and do not require a physician's order.

Based on observation, interview, and record review, the facility failed to store and manage medication in accordance with currently accepted professional principles for 1 of 3 medication rooms and 2 of 3 medication(emergency cart) and 1 of 1 treatment carts reviewed for storage and labeling of medications, in that: 1. The emergency crash cart for floor 100 contained expired items. 2. The treatment cart on floor 200 was left unattended and unsecured. 3. The emergency crash cart located on floor 300 contained expired items. 4. The medication room located on floor 300 contained an opened item with no open date. These deficient practices could affect residents on medication and could result in administration of expired or degraded medication and failure to secure the treatment cart provided an opportunity to put Residents that are confused or disoriented at risk for potential injury from harmful chemicals. Findings Included: 1.Observations on 5/18/2022 at 7:45 a.m. of the emergency crash cart located by the nurse's station on 1st floor contained: 50% dextrose injection with an expiration date of 12/014/2021, six gold top blood collection tubes with an expiration date of 10/31/2020, metoprolol 5mg/5ml for IV use with an expiration date of 05/01/2022. Interview conducted with LVN C on 5/18/2022 at 08:00 a.m., LVN C stated the charge nurses are responsible for checking medications and supplies in the emergency crash cart, medication rooms, and medication carts for expired items and place them in the container provided for medication destruction daily. She stated it is important to remove expired items to assure that medications and supplies are within their therapeutic range. 2. Observation on 5/18/2022 at 8:00 a.m. of 1 of 1 treatment cart parked in the hallway on the first floor was left unattended and unlocked. The treatment cart contained multiple items such as: Alcohol 75% spray, antimicrobial gel, zinc oxide, hibiclens wound cleanser, peroxide, alginate wound dressings, collagen powder, scissors and multiple bandages and dressings. Interview conducted with LVN D on 5/18/2022 at 8:05 a.m., she confirmed that the treatment cart was left unlocked. She stated all treatment and medication carts should be secured if they are unattended because of the potential danger of a confused resident obtaining access to items that could be harmful if swallowed or placed in their eyes. 3. Observation on 5/18/2022 at 8:20 a.m. of the emergency crash cart located by the nurse's station on the 3rd floor revealed it contained one 1000 cc IV bag of lactated ringers ( often used to restore hydration status) with an expiration date of June 2021, and two red top blood tube collection vials with an expiration date of 12/21/2021. Interview conducted with RN A on 5/18/2022 at 8:25 a.m., she stated the nurses are responsible for checking the emergency cart for expired items. She stated that the carts are checked daily on the night shift and it is important to remove items when they expire due to the potential for bacterial growth. 4. Observation on 5/18/2022 at 8:27 a.m. of the medication room located on the 3rd floor revealed one bottle of mag citrate (normally used as a bowel prep before surgery or a procedure) that had been opened and not labeled with an opened date. Interview conducted with RN A on 5/18/2022 at 8:28 a.m., she stated all nurses are required to date any item opened in the medication room. She further stated that dating was important to monitor the shelf life of medications because if an item is passed its shelf life it may not have the required therapeutic benefit. Interview conducted with the CNO on 5/20/2022 at 10:37 a.m., she stated the charge nurses are supposed to be routinely checking all medication storage areas for expired medications or supplies and removing them from use. She stated that it is important to remove these items to ensure the safety of the residents. Interview conducted with the GM on 5/20/2022 at 2:30 p.m., she stated that it is the responsibility of the charge nurses to ensure that medication rooms and carts are being monitored for expired items and discarded by procedures. She further stated that it is also the responsibility of the consultant pharmacist that comes once a month to inspect the medication rooms and medication carts to be monitoring for expired items. Record review of policy titled, Medication Labeling & Storage, dated January 2020 reflected that medications were labeled in accordance with facility requirements and state and federal laws. All drug containers would be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirements. Record review of policy titled, Disposal of Medications and Medication-related Supplies, dated December 2017, section D reflected, the facility should maintain approved containers to separate and securely store different types of pharmaceutical waste until it was scheduled for pick up. Section E reflected, authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Section L reflected, facilities should train all employees who handle pharmaceuticals on the appropriate management and disposal of pharmaceutical waste and emergency procedures upon hire and regularly according to regulation or applicable law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for 9 of 24 Residents (Residents #10, #12, #86, #91, #158, #161, #258, #259, #264) reviewed for medical records, in that: 1. The facility did not document Residents #12 and #161's code status' as Full Code in EHR 2. The facility did not obtain physician's orders for Residents #86, #91, and #158, code status' of Full Code. 3. The facility did not document Residents #10, #258, #259, and #264's code status' as a Full Code in residents EHR. These deficient practices could place residents at risk for improper care due to inaccurate records. The findings were 1. Record review of Resident #12's face sheet, dated [DATE], revealed the resident was admitted [DATE] with diagnoses that included: acute respiratory failure with hypoxia (don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), disorientation, altered mental status, pneumonitis due to inhalation of other solids and liquids (occurs when an irritating substance causes the tiny air sacs (alveoli) in your lungs to become inflamed), dysphagia (difficulty swallowing), dementia, hypertension (high blood pressure), and pulmonary hypertension (when the pressure in the blood vessels leading from the heart to the lungs is too high). Record review of Resident #12's EHR revealed that MDS was not due for completion at the time Record review of Resident #12's Physician Order Summary dated [DATE] revealed no code status entered as an order. Record review of Resident #12's EHR revealed no code status in the banner located under the resident's name in her EHR. Record review of Resident #161's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (common after-effect of stroke that causes weakness on one side of the body), encephalopathy (damage or disease that affects the brain), aphasia (condition that affects your ability to communicate), hypertension (high blood pressure), and hypokalemia (lower than normal potassium level in your bloodstream). Record review of Resident #161's EHR revealed that MDS was not due for completion at the time Record review of Resident #161's Physician Order Summary dated [DATE] revealed no code status entered as an order. Record review of Resident #161's EHR revealed no code status in the banner located under the resident's name in her EHR. 2. Record review of Resident #86's face sheet, dated [DATE], revealed the resident was admitted [DATE] with diagnoses that included: chronic diastolic (congestive) heart failure (occurs if the left ventricle muscle becomes stiff or thickened), chronic atrial fibrillation unspecified (heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly lasting longer than a week), hypertension (high blood pressure), pulmonary hypertension (when the pressure in the blood vessels leading from the heart to the lungs is too high), interstitial pulmonary disease (a large group of disorders, most of which cause progressive scarring of lung tissue), displaced intertrochanteric (specific type of hip fracture) fracture of right femur, encounter for closed fracture with routine healing, acute kidney failure unspecified (sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), and hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream). Record review of Resident #86's Admission/5-day MDS, dated [DATE], revealed the resident's BIMS was not assessed. Record review of Resident #86's Nursing Evaluation described as admission dated [DATE] revealed Section A. Demographics/Orientation to Facility, 1. admission Details, 1. Reason for Evaluation admission, Section f Resident code status (need physician order) Full Code. Record review of Resident #86's care plan initiated on [DATE] revealed a care plan for Resident is a FULL CODE. Record review of Resident #86's Physician's Order Summary dated [DATE] revealed no code status entered as an order. Record review of Resident #86's EHR revealed no code status in the banner located under the resident's name in her EHR. Record review of Resident #91's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: infection and inflammatory reaction due to internal left hip prosthesis, presences of left artificial hip joint, methicillin resistant staphylococcus aureus infection as the cause of diseases, hypokalemia (lower than normal potassium level in your bloodstream), acute posthemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating hemoglobin), obstructive sleep apnea (adult) (when the muscles in the back of your throat relax too much to allow normal breathing), hyperlipidemia (your blood has too many lipids (fats) in it), major depressive disorder, and hypertension (high blood pressure). Record review of Resident #91's Nursing Evaluation described as readmission dated [DATE] revealed Section A. Demographics/Orientation to Facility, 1. admission Details, 1. Reason for Evaluation admission, Section f Resident code status (need physician order) Full Code. Record review of Resident #91's 5-day MDS, dated [DATE], revealed resident's BIMS was not assessed. Record review of Resident #91's care plan initiated on [DATE] revealed a care plan for Resident is a FULL CODE. Record review of Resident #91's Physician Order Summary dated [DATE] revealed no code status entered as an order. Record review of Resident #91's EHR revealed no code status in the banner located under the resident's name in his EHR. Record review of Resident #158's face sheet, dated [DATE], revealed the resident was admitted to the facility [DATE] with diagnoses that included: infection and inflammatory reaction due to internal right knee prosthesis, arthritis due to other bacteria right knee, long term use of antibiotics, acute posthemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating hemoglobin), muscle wasting and atrophy, hyperlipidemia (your blood has too many lipids (fats) in it), major depressive disorder, insomnia (difficulty falling asleep at night), bipolar (mental health condition that causes extreme mood swings) disorder, hypertension (high blood pressure), and unspecified osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time). Record review of Resident #158's Nursing Evaluation described as admission dated [DATE] revealed Section A. Demographics/Orientation to Facility, 1. admission Details, 1. Reason for Evaluation admission, Section f Resident code status (need physician order) Full Code. Record review of Resident #158's Admission/5-day MDS, dated [DATE], revealed resident's BIMS was not assessed. Record review of Resident #158's Physician's Order Summary dated [DATE] revealed no code status entered as an order. Record review of Resident #158's EHR revealed no code status in the banner located under the resident's name in her EHR. During interview on [DATE] at 3:57 a.m. RN A stated when a resident was a DNR they would make sure the resident had an OOHDNR signed and that it would be in the miscellaneous tab of the EHR. RN A further stated a resident's Full Code status was verified in the electronic charting system and the physician's orders. RN A stated Resident #12's EHR did not have an order for Full Code. During an interview on [DATE] at 4:05 p.m. LVN F stated usually a resident's code status was in the electronic charting system on the header near the special instructions. LVN F further stated if a resident did not have an OOHDNR on file staff would administer CPR (Cardiopulmonary Resuscitation). LVN F stated Resident's #91, #158, and #161 did not have an order for Full Code. LVN F stated the code status was also available on the MAR/TAR and if it was not present staff would automatically start CPR. 3. Record review of Resident #10's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure (usual exchange between oxygen and carbon dioxide (CO2) in the lungs does not occur), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), anxiety disorder (a persistent feeling of anxiety or dread), major depressive disorder (persistently depressed mood and long-term loss of pleasure or interest in life), and altered mental status. Record review of Resident #10's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #10's EHR revealed no code status entered as an order nor in the banner located under the resident's name in his EHR. Record review of Resident #258's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), altered mental status, and part of right femur fracture. Record review of Resident #258's MDS' revealed he did not have a completed MDS in her EHR. Record review of Resident #258's EHR revealed no code status entered as an order nor in the banner located under the resident's name in her EHR. Record review of Resident #259's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dependence on supplemental oxygen, pulmonary fibrosis (thickening or scarring of lung tissue), rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), major depressive disorder, and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #259's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #259's EHR revealed no code status entered as an order nor in the banner located under the resident's name in his EHR. Record review of Resident #264's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), anxiety disorder, major depressive disorder, and seizures. Record review of Resident #264's MDS' revealed he did not have a completed MDS in his EHR. Record review of Resident #264's EHR revealed no code status entered as an order nor in the banner located under the resident's name in his EHR. During an interview on [DATE] at 3:58 p.m., CNA C stated she would look in the residents' EHR to see what their code status was and if not, there was nothing in the system then she would ask that residents nurse. During an interview on [DATE] at 4:02 p.m., LVN E stated a resident's code status was supposed to show up right under the resident's name in the EHR. She further stated the code status was also under the order, which is how it comes up as a banner under their name. LVN E stated that if there was no order and no code status in the banner under the name then the resident is automatically considered FC. She also said if resident showed as a DNR under the banner but there was no DNR in the system then that resident was also considered FC. During an interview on [DATE] at 10:35 a.m. the CNO stated residents code statuses will pop up in the little header on the EMR and if it was not there the residents were considered a Full Code if there was not clarification of the DNR status. The CNO further stated the physician orders should include the code status and that social services were responsible for getting the code statuses, then social services would let the nurses know and the nurses would write the order. The CNO stated regardless if a resident was a DNR or a full code that there was supposed to be an order entered in PCC. The CNO stated that any nurse could put in the code status orders and then the code status would be care planned. After reviewing the EMR base line care plan the CNO stated that code status was not part of it, so it would be initiated into the care plan. The During an interview on [DATE] at 1:29 p.m. the DCT stated when nurses would get reports they would alert social services if the resident had a DNR reported from the hospital, but the nurses did not have the paperwork. The DCT further stated that once the nurses complete the nursing evaluation the nurse would write the order for Full Code if that had been the decision. The DCT also stated residents were treated as a full code if there were no orders entered. She then stated the admitting nurse was the one responsible for completing a code status. The DCT stated a resident was only considered a DNR when the actual completed DNR was uploaded into the system. She further stated floor staff would treat a resident as full code if there was not actual DNR signed in the EHR. She also stated the potential harm was a resident not having their wishes implemented regardless of wanting to be full code or a DNR. During an interview on [DATE] at 2:27 p.m., the GM stated the code statuses showed on PCC, should be ordered as a Full Code or a DNR and could be pulled up in the orders to be seen. The GM further stated when a resident was admitted it was in the admission packet, but if they don't have a DNR they were made Full Code, then social services would meet with them to complete OOHDNRs, and the nurses should put the orders in PCC for Full Code whoever did the admission. The GM also stated she believed a resident's code status showed up as a ribbon under their name. She then stated the code status showed up on the ribbon after an order was entered into PCC. The GM stated when the resident was admitted in the if there was no DNR then the resident is automatically a full code. She also stated the admission nurse was responsible for entering the resident's code status as an order. The GM stated if the resident requested to be a DNR then the floor staff would refer to social services. She then stated a resident was not considered a DNR until the DNR was fully completed and signed. The GM stated the potential harm to the resident was the resident's wishes not being followed through and with not having a code status in the resident's EHR, could delay our reaction to a resident that needed an immediate response to them coding. Record review of facility's policy ADVANCE DIRECTIVES AND DNR POLICY, dated 11/2014, did not specifically address a resident's code status being entered in their EHR, nor did the policy address a resident's EHR needing an order that stated the resident's code status preference. Record review of facility's policy Physician's Orders, dated [DATE], did not specifically address a resident's code status being entered in their EHR, nor did the policy address a resident's EHR needing an order that stated the resident's code status preference.