**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #3) whose assessments were reviewed. The facility failed to indicate Resident #3 received oxygen on her Quarterly MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments.The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed she was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) and the resident received supplemental oxygen. Record review of Resident #3's Quarterly MDS Assessment, dated 09/07/2025, revealed a BIMS score of 15 out of 15 which indicated her cognitive skills for daily decision making were not impaired, and under Section O it was not checked she received oxygen. Record review of Resident #3's care plan, initiated 06/30/2025, for the focus area of I have oxygen therapy related to ineffective gas exchange, and respiratory illness revealed under Interventions was to administer oxygen at 2 LPM via nasal cannula (a specialized tube with prongs into the nose that delivers oxygen from an oxygen concentrator) to maintain blood oxygen saturations above 92%. Record review of Resident #3's Physician's Order Summary, dated 09/28/2025, revealed there was no order for oxygen administration. Record review of Resident #3's electronic clinical record vital signs sections for blood oxygen saturation revealed on 09/03/2025, 09/05/2025 and on 09/07/2025 she received oxygen via nasal cannula. Observation on 09/28/2025 at 8:52 AM revealed Resident #3 was in bed and received oxygen at 2 LPM via nasal cannula. Interview on 09/29/25 at 12:51 PM, the MDS Nurse stated she would look at the resident's entire electronic clinical record and/or their hospital record when the MDS was completed to ensure it was accurate. The MDS Nurse reviewed Resident #3's Quarterly MDS dated [DATE] and stated the oxygen was not checked because she had reviewed the MARs which did not indicate the resident had received oxygen. The MDS Nurse reviewed Resident #3's vital signs section in the electronic clinical record for oxygen saturation and verified Resident #3 received oxygen during the look-back period the MDS was completed and the MDS should have been checked the resident received oxygen. The MDS Nurse stated she was responsible for ensuring the MDS was completed accurately and the harm of not having the MDS completed accurately could result in other health care members not know the resident needed oxygen. In an interview on 09/29/25 at 1:53 PM, the Executive Clinician stated the MDS Nurse was responsible for ensuring the accuracy of the MDS assessments and the harm of an inaccurate MDS could result inaccurate plan of care for the resident. In an interview on 09/29/2025 at 2:13 PM, the Executive Director stated the Executive Clinician and the Corporate MDS Nurse oversaw the residents' MDS assessments to ensure they were accurate and if the MDS assessment was not completed accurately, then the care administered to the resident might not be appropriate for the resident. Record review of CMS's RAI Version 3.0 Manual, dated October 2025, CH 3: MDS Items O, page O-4, revealed under Section O, oxygen should be checked if a resident received oxygen either continuous or intermittent in the past 14 days. Record review of the facility's policy Resident Assessment Instrument, revised December 2024, revealed a comprehensive assessment of a resident's needs shall be made withing fourteen (14) days of the resident's admission. 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews.3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #3) reviewed for respiratory care. Resident #3 received oxygen at 2 liters per minute via nasal cannula without a physician order. This failure could affect residents with oxygen therapy and could lead them to a lack of care.The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed Resident #3 was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) and the resident received supplemental oxygen. Record review of Resident #3's Quarterly MDS Assessment, dated 09/07/2025, revealed a BIMS score of 15 out of 15 which indicated her cognitive skills for daily decision making were not impaired, and it was not checked she received oxygen. Record review of Resident #3's care plan, initiated 06/30/2025, for the focus area of I have oxygen therapy related to ineffective gas exchange, and respiratory illness, revealed under Interventions was to administer oxygen at 2 LPM via nasal cannula (a specialized tube with prongs into the nose that delivers oxygen from an oxygen concentrator) to maintain blood oxygen saturations above 92%. Record review of Resident #3's Physician's Order Summary, dated 09/28/2025, revealed there was no order for oxygen administration. Record review of Resident #3's electronic clinical record vital signs section for blood oxygen saturation revealed on 09/03/2025, 09/05/2025, 09/07/2025, 09/09/2025, 09/10/2025, 09/11/2025, 09/12/2025, 09/14/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/19/2025, 09/21/2025, 09/24/2025, 09/25/2025, 09/26/2025, 09/27/2025, and 09/28/2025 Resident #3 received oxygen via nasal cannula. Observation on 09/28/2025 at 8:52 AM revealed Resident #3 was in bed and received oxygen at 2 LPM via nasal cannula. In an interview on 09/28/25 at 2:44 PM, after LVN A reviewed Resident #3's physician orders, she stated the resident did not have an order for oxygen and Resident #3 should have an order since the resident received oxygen. LVN A stated the harm of not having an order for oxygen could cause respiratory distress if she [the resident] didn't have it [oxygen] or too much [oxygen] could be administered. In an interview on 09/29/25 at 1:53 PM, the Executive Clinician stated when a resident received oxygen, they should have an order for the oxygen and the harm of not having an order could result in the oxygen treatment not being monitored. The Executive Clinician said she and the ADON were responsible for ensuring the resident's clinical records were accurate and they would review the orders from the hospital when the resident was admitted or readmitted to the facility to ensure the orders were accurate. In an interview on 09/29/2025 at 2:13 PM, the Executive Director stated when a resident received oxygen it should be documented in their clinical record, in their plan of care, and there should be an order for the oxygen. The Executive Director stated the harm of not having an order for oxygen was there would not be any documentation that it was ordered by the physician and any treatment would have to have a doctor's order. Record review of the facility's policy Oxygen Administration, revised October 2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. Based on observation, interview, and record review, the facility failed to ensure Quarterly comprehensive assessment accurately reflected the resident's status for 1 of 6 [Resident #33] residents reviewed for accuracy of assessments in that Residen #33's diagnosis was not coded. 1. The facility failed to accurately code Resident #33 diagnosis status on the quarterly comprehensive assessment dated [DATE] and quarterly comprehensive assessment dated [DATE]. These failures could place resident at risk for improper or incorrect care and services necessary for their physical, mental and psychosocial well-being. The findings include: 1. Record review of Resident #33 admission Record dated 12/06/24 revealed resident was initially admitted [DATE], re-admitted [DATE] and was [AGE] years old. 2. Record review of Resident #33 Medication Review Report dated 12/05/24 revealed diagnoses to include Adjustment Disorder with Anxiety. 3. Record review of Resident #33 Medication Administration Record (MAR) for [DATE], [DATE] and [DATE] revealed resident was receiving buspirone HCL oral tablet 10mg (Buspirone HCL) with directions to Give 1 tablet by mouth three times a day for anxiety, start date 09/21/2024. 4. Record review of Resident #33 Quarterly MDS dated [DATE] and 11/02/24, Section N, Medications N0415 High Risk Drug Classes, Section 1 was Taking and Section 2 Indication Noted, B is checked for antianxiety medication. Record review of Resident #33 Minimum Data Set (MDS) dated [DATE] and 11/02/24, Section I-Active Diagnoses, Psychiatric / Mood Disorder I5700. Anxiety Disorder do not reflect diagnosis of anxiety. 5. Record review of Resident #33 Minimum Data Set (MDS) dated [DATE] and 11/02/24, Section I-Active Diagnoses, Psychiatric / Mood Disorder I5700. Anxiety Disorder do not reflect diagnosis of anxiety. During interview with MDS RN A on 12/05/24 at 12:08 PM, MDS RN A confirmed resident was receiving buspirone for anxiety per physicians' order. MDS RN A confirmed MDS dated [DATE] and MDS dated [DATE] do not reflect a diagnosis of anxiety. MDS RN A reflected that this discrepancy is inaccurate and stated inaccuracy does not affect payment schedule and will be addressed accurately on next scheduled MDS. During interview with MDS RN A on 12/05/24 at 10:08 PM, MDS RN A confirmed she is the MDS Coordinator and completed section I for MDS dated [DATE] and MDS dated [DATE]. MDS RN A confirmed she wass the RN assessment coordinator and verified assessment completion. Record review of facility policy Resident Assessment Instrument reviewed December 2023, Policy Interpretation and Implementation, revealed, 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. Record review of CMA MDS 3.0 RAI User's Manual v1.19.1 effective 10/01/2023 CH 3: MDS Items [I}revealed that Active Diagnosis in the last 7 days are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. During interview with DON on 12/05/24 at 12:50 p.m. revealed that these failures could place resident at risk for improper or incorrect care and services necessary for their physical, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 11.54%, based on 3 errors out of 26 opportunities which involved 2 of 2 residents (Resident #52 and #18) and 1 MA, reviewed for medication administration and medication errors. 1.) The facility failed to ensure medications were administered timely for Resident #52 on 12/5/2024. 2.) The facility failed to ensure medications were administered timely for Resident #18 on 12/5/2024. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. The findings included: 1.) Record review of the Face Sheet printed 12/6/2024, reflected Resident #52 was a [AGE] year-old male originally admitted on [DATE]. Record review of the Diagnosis Report printed on 12/6/2024, reflected Resident #52 had the following diagnoses: chronic kidney disease [long term condition that affects the organ that filters waste products and extra fluids from the body which helps control blood pressure], hypertensive heart disease [long term condition that develops after many years of high blood pressure] with heart failure [thickening and weakening of the heart muscle which makes pumping the blood more difficult], and hypertension [high blood pressure]. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #52 had a BIMS summary score of 15, indicative of intact cognition. High-risk drug classes section reflected Resident #52 was taking diuretics [medications that promote removal of salt and fluid from the body, helps reduce excess fluid, and lower blood pressure]. Resident #52 was coded as having received scheduled and PRN pain relieving medications in the last 5 days of the assessment, with a frequency of experiencing pain almost constantly. Record review of the Care Plan printed on 12/6/2024, reflected Resident #52 had a focus area of fluid overload or potential fluid volume overload related to chronic kidney disease; with the following associated interventions: administer medications as ordered, with a date initiated 4/17/2024. Additional focus area of I have (acute/chronic [unspecified]) pain; with the following associated interventions: administer analgesia [pain relief medication] as per orders with a date initiated 4/18/2024; evaluate the effectiveness of pain interventions; review for compliance, alleviating of symptoms, dosing schedules . with date initiated 4/18/2024. Further focus area of I am on diuretic therapy; with the following associated interventions: administer medication as ordered, with a date initiated 6/24/2024. Record review of the Order Summary Report printed on 12/6/2024, reflected Resident #52 had the following active physician orders: bumex [a medication to help remove excessive fluid in the body] oral tablet 1 mg, give one tablet by mouth three times a day for diuretic, with a start date of 11/30/2024; gabapentin [a medication for nerve pain] oral capsule 100 mg, give one capsule by mouth three times a day for neuropathy [nerve] pain, with a start date of 11/30/2024. In an observation on 12/05/2024 at 8:54 AM, MA F administered the following medications to Resident #52: bumex and gabapentin. Both medications were due at 7:00 AM. Review of Medication Admin Audit Report, printed 12/5/2024, reflected Resident #52 had bumex and gabapentin administered at 8:54 AM by MA F, when the medications were scheduled for 7:00 AM. 2.) Record review the Face Sheet printed 12/6/2024, reflected Resident #18 was a [AGE] year-old female originally admitted on [DATE]. Record review of the Diagnosis Report printed on 12/6/2024, reflected Resident #18 had the following diagnoses: type 2 diabetes mellitus [metabolic disorder marked by impaired ability to produce or respond to insulin with diabetic neuropathy and hereditary [passed down from parents to offspring] and idiopathic [spontaneous, or from an obscure or unknown cause] neuropathy. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #18 had a BIMS summary score of 15, indicative of intact cognition. Resident #18 was coded as having received scheduled and PRN pain relieving medications in the last 5 days of the assessment, with a frequency of experiencing pain almost constantly. Record review of the Care Plan printed on 12/6/2024, reflected Resident #18 had a focus area of I have (acute/chronic [unspecified]) pain; with the following associated interventions: administer analgesia [pain relief medication] as per orders with a date initiated 5/01/2024. Record review of the Order Summary Report printed on 12/05/2024, reflected Resident #18 had the following active physician orders: gabapentin oral capsule 600 mg, give one capsule by mouth two times a day for neuropathy pain, with a start date of 6/27/2024. In an observation on 12/05/2024 at 9:08 AM, MA F administered the following medication to Resident #18: Gabapentin. This medication was due at 7:00 AM. Review of Medication Admin Audit Report, printed 12/5/2024, reflected Resident #18 had gabapentin administered at 9:08 AM by MA F, when the medication was scheduled for 7:00 AM. In an interview on 12/5/2024 at 11:48 AM, MA D stated policy allows for medication administration up to one hour prior to the scheduled time and up to one hour after the scheduled time . In an interview on 12/5/2024 at 11:59 AM, LVN E stated policy allows for medication administration up to one hour prior to the scheduled time and up to one hour after the scheduled time . LVN E stated that pharmacy does spot checks monthly but was unsure of the scope or outcome. In an interview on 12/06/2024 at 11:36 AM, the DON stated medications were to be administered within the designated time window as per the physician's order. The DON further explained medications could be administered in the hour prior to the scheduled time, or up to an hour after the schedule time. The DON stated this information was provided at new hire on-boarding, during annual competency assessments, and in in-service trainings as needed. The DON stated the risk for not receiving medications timely, could be a change in the expected therapeutic response. Record review of Medication Administration Schedule policy, revised December 2023, reflected under the heading Policy Interpretation and Implementation, 1.) Medications are to be administered according to the following routine schedule. They may be changed due to patient preference/sleep patterns/pharmacy recommendations [schedule for either TID or BID medications, reflected morning administration would be 8:00 AM]. 2.) Routine medication administration schedules may be changed only by submitting a request to the corporate office. Administration times can be changed to meet each facility's unique resident population. 3.) A physician's order for specific times supersedes any routine schedule. 4.) Resident may request alternate medication schedules. Such times must be documented on the MAR and CP. Review of Lippincott procedures, Safe Medication administration practices, long-term care, accessed from https://procedures.lww.com/lnp/view.do?pId=4419880&hits=medications,medication,administration&a=true&ad=false&q=medication%20administration, on 12/05/2024, revised on 5/19/2024, reflected under the heading Introduction, instructions .administer the medication at the right time . Under the heading Ensuring timely administration of scheduled medication, instructions, Be sure to administer medications that require more frequent administration than daily but not more frequently than every 4 hours (two or three times per day [BID or TID]) within 1 hour of their scheduled administration time. Record review of the National Library of Medicine's website, Nursing Rights of Medication Administration - StatPearls - NCBI Bookshelf, accessed from https://www.ncbi.nlm.nih.gov/books/NBK560654/#:~:text=It%20is%20standard%20during%20nursing%20education%20to%20receive,%E2%80%98five%20rights%E2%80%99%20or%20%E2%80%98five%20R%E2%80%99s%E2%80%99%20of%20medication%20administration.), accessed 12/10/2024, entitled Nursing Rights of Medication Administration updated 09/04/2023, revealed, Definition/Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2]; The five traditional rights in the traditional sequence include: . 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #31) reviewed for medication administration. Resident #31 was provided medications, Amlodipine Besylate and Carvedilol, outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #31's face sheet, dated 12/5/2024, reflected an [AGE] year-old resident with an initial admission date of 4/8/2023 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (condition that affects one side of the body usually caused by a stroke that can cause paralysis), unspecified atrial fibrillation (a heart condition that causes an irregular and often rapid heartbeat), and hypertension (high blood pressure). Record review of Resident #31's quarterly MDS assessment, dated 11/12/2024, reflected Resident #31 was assessed with a BIMS score of 8 out of a possible 15 which indicated moderate cognitive impairment. Record review of Resident #31's comprehensive person-centered care plan revealed Resident #31 had coronary artery disease r/t Atherosclerosis (a disease that occurs when plaque builds up in the inner lining of arteries), atrial fibrillation (a heart condition that causes an irregular and often rapid heartbeat), hypercholesterolemia (a condition where there are abnormally high levels of fat in the blood), and hypertension (high blood pressure) initiated on 11/29/2024, with interventions to, Give all cardiac meds as ordered by physician. Record review of Resident #31's Order Summary Report, dated 12/6/2024, reflected an order for Amlodipine Besylate Oral Tablet 5 MG (amlodipine Besylate) give 2 tablet via PEG-Tube one time a day for Hypertension give 2 tablets equal to 10 mg daily hold for systolic less than 110 and HR less than 60 indicating the medication should not be provided to the resident if their systolic blood pressure (the top number, which measures the pressure in your arteries when your heart beats) is over 110 or when the residents heart rate was under 60 beats per minute. Further review reflected an order for Coreg Oral Tablet 12/5 MG (Carvedilol) Give 1 tablet via PEG-Tube two times a day for hypertension hold for systolic less than 110 and HR less than 60 indicating the medication should not be provided to the resident if their systolic blood pressure (the top number, which measures the pressure in your arteries when your heart beats) was less than 110 or when the residents heart rate was less than 60 beats per minute. Record review of Resident #31's November 2024 medication administration record dated 12/5/2024, reflected Resident #31 could have been administered Amlodipine Besylate 30 times from 11/1/2024 through 11/30/2024 and was administered Amlodipine Besylate out of parameters as follows: 1. On 11/4/2024, LVN L administered Amlodipine Besylate to Resident #31 while his pulse was 57 at 9:00 AM. 2. On 11/6/2024, LVN L administered Amlodipine Besylate to Resident #31 while his pulse was 56 at 9:00 AM. 3. On 11/8/2024, LVN M administered Amlodipine Besylate to Resident #31 while his pulse was 58 at 9:00 AM. 4. On 11/12/2024, LVN L administered Amlodipine Besylate to Resident #31 while his Systolic Blood Pressure was 101 at 9:00 AM. 5. On 11/18/2024, LVN L administered Amlodipine Besylate to Resident #31 while his pulse was 57 at 9:00 AM. Record review of Resident #31's November 2024 medication administration record, dated 12/5/2024, reflected Resident #31 could have been administered Carvedilol 60 times from 11/1/2024 through 11/30/2024 and was administered Carvedilol out of parameters as follows: 1. On 11/4/2024, LVN L administered Carvedilol to Resident #31 while his pulse was 57 at 9:00 AM. 2. On 11/6/2024, LVN L administered Carvedilol to Resident #31 while his pulse was 56 at 9:00 AM. 3. On 11/8/2024, LVN M administered Carvedilol to Resident #31 while his pulse was 58 at 9:00 AM. 4. On 11/12/2024, LVN L administered Carvedilol to Resident #31 while his Systolic Blood Pressure was 101 at 9:00 AM. 5. On 11/15/2024, LVN N administered Carvedilol to Resident #31 while his Systolic Blood Pressure was 103 at 9:00 PM. 6. On 11/18/2024, LVN L administered Carvedilol to Resident #31 while his pulse was 57 at 9:00 AM. 7. On 11/19/2024, LVN N administered Carvedilol to Resident #31 while his [NAME] was 59 at 9:00 PM. 8. On 11/25/2024, LVN N administered Carvedilol to Resident #31 while his [NAME] was 58 at 9:00 PM. Interview on 12/6/2024 at 11:03 AM, LVN M stated that when providing residents medications that have parameters, the required vitals such as blood pressure and pulse were taken before giving the resident the medication. LVN M stated that they regularly have training on medication administration to include parameters, and that there were also regular competency checks to ensure medications were being given within appropriate parameters. LVN M stated that he did not work the hall that Resident #31 was on frequently and was not very familiar with his care . Interview on 12/6/2024 at 11:16 AM, the DON stated that parameters for medications were to ensure that the medications were provided when necessary and so that if a resident was consistently out of parameters, they could request that the physician review the medications and parameters to see if any necessary changes needed to be made. The DON stated she was not aware of the medications being provided out of parameters and that her expectation for if a medication was provided out of parameters would be to inform the residents physician and the DON and to monitor after the fact to ensure there were no adverse effects. Record review of Facility Policy titled, Medication Error or Adverse Consequences, dated reviewed December 2023, reflected, A 'medication error' is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 8 residents (Resident #2) reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #2 was provided with a divided plate to meet Resident #2's need for assistance while eating. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. The findings included: Record review of Resident #2's face sheet, dated 12/6/2024, reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (condition that affects one side of the body usually caused by a stroke that can cause paralysis), a traumatic brain injury, and a cerebral infarction (stroke). Record review of Resident #2's Quarterly MDS Assessment, dated 9/28/2024, reflected a BIMS score of 13, indicating that the resident's cognition was intact. Further record review reflected that Resident #2 needed setup or clean-up assistance with eating. Record review of Resident #2's Comprehensive Person-Centered Care Plan, undated, reflected that Resident #2 used a divided plate to assist with meals. Record review of Resident #2's order summary report, dated 12/6/2024, reflected an order for a Modified diabetic (CC) diet Regular Texture, Thin (Level 0 - Thin) consistency, L7 texture, Divided Plate, 2 handle or mug with lid, with an order start date of 4/24/2024. Observation and record review on 12/3/2024 at 1:13 PM reflected a meal ticket with Resident #2's name on it, reflecting Assist Instructions: Divided Plate/Sippy Cup. A regular, flat, undivided plate was observed to be on Resident #2's plate. Resident #2 was observed to be struggling with his meal, to include spilling his coleslaw after struggling to pick up the bowl it was in. There were no observations of staff interference until the state surveyor intervention. Resident #2 completed his meal in an undivided plate. Other residents were observed to have divided plates. Interview on 12/6/2024 at 11:20 AM, the DON stated that if there was an assistive device ordered, it should come out on the tray. The DON stated that if the assistive device was not on the tray, it should be noticed by the nurse who was tasked with checking the resident's meal tickets and comparing them to what was on the tray before they were given to residents . Record review of Facility Policy, undated, titled, Assistive Devices and Equipment, reflected, Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 infections for 5 (Residents #27, #38, #9, #2, and #49) of 8 residents observed for infection control. 1. The facility failed to ensure Resident #27's Foley catheter bag was not touching the floor twice on 12/03/2024. 2. The facility failed to ensure Resident #38's Foley catheter bag was not touching the floor on 12/03/2024. 3. The facility failed to ensure Resident #9's Foley catheter bag was not touching the floor on 12/03/2024 and on 12/05/2024. 4. The facility failed to ensure Resident #2's Foley catheter bag was not touching the floor on 12/03/2024 and on 12/05/2024. 5. The facility failed to ensure Resident #49's Foley catheter bag was not touching the floor on 12/06/2024. These failures could place residents at risk for cross contamination, urinary tract infections, hospitalization, resulting in a decline in well-being. Findings included: 1. Record review of the Face Sheet printed on 12/06/2024 reflected Resident #27 was a [AGE] year-old female originally admitted on [DATE]. Record review of the Diagnosis Report printed on 12/06/2024 reflected Resident #27 had the following diagnoses: Parkinson's Disease [movement disorder of the nervous system that worsens with time], stage 4 pressure injury to right lower back and sacral region [back and buttocks area], and malignant neoplasm [cancerous tumor] of anus. Record review of the comprehensive MDS assessment dated [DATE], reflected Resident #27 had a BIMS summary score of 15, indicative of intact cognition. Resident #27 had an indwelling catheter. Record review of the Care Plan printed on 12/06/2024, reflected Resident #27 had an indwelling catheter related to stage 4 pressure injuries to scrum[sp] and right ischium; however, the CP did not include interventions for the care or management of the Foley Catheter. Record review of the Order Summary Report printed 12/06/2024 reflected Resident #27 had physician's orders for Foley Catheter 16 French with 10 ml balloon for pressure injury with a start date of 12/02/2024. In an observation on 12/03/2024 at 10:30 AM, Resident #27 was observed with the Foley catheter drainage bag sitting on the floor. In an observation and interview on 12/03/2024 at 2:38 PM, Resident #27 was observed with the Foley catheter drainage bag sitting on the floor. Resident #27 stated she has had the catheter for a long time. 2. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #38 was a [AGE] year-old female, admitted on [DATE]. Resident #38's BIMS summary score was 11, indicative of moderately impaired cognition. Resident #38's active diagnoses included: renal insufficiency, renal failure, or end-stage renal disease [kidneys are not functioning at their full capacity], and neurogenic bladder [muscles in the bladder wall do not contract and relax properly, causing problems with urination]. Resident #38 was coded as having an indwelling urinary catheter. In an observation on 12/03/2024 at 10:50 AM Resident #38 was observed with the Foley catheter bag touching the floor. 3. Record review of the Face Sheet printed 12/06/2024 reflected Resident #9 was a [AGE] year-old female originally admitted on [DATE]. Record review of the Diagnosis Report, printed on 12/06/2024 reflected Resident #9 had the following diagnoses: Stage 4 pressure injury of the left lower back and sacral region, and type 2 diabetes mellitus. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #9 did not have a BIMS conducted due to being rarely/never understood, with short-, and long-, term memory problems, and moderately impaired cognitive skills for daily decision making. Resident #9 was coded as having an indwelling urinary catheter. Record review of the Order Summary Report printed 12/06/2024 reflected Resident #9 had a physician's order for Foley Catheter, 18 French [indicative of the size of the tubing] with 10 ml NS balloon [10 ml normal saline filled balloon holds the tubing inside the bladder] for patency every shift, with an order date of 10/10/2024. Additional orders included: keep the urinary drainage bag below the level of the blader at all times every shift and as needed, with an order date of 8/13/2024. Record review of the Care Plan printed 12/04/2024 reflected Resident #9 had a focus area of I have indwelling catheter related to pressure injury to left ischium and sacrum, stage 4; with the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door. [CP did not address keeping the Foley catheter bag off the floor.] In an observation on 12/03/2024 at 1:09 PM, Resident #9 was seated in an extra tall-backed wheelchair, being assisted with her meal in the dining room. The Foley catheter bag was hooked under the seat of the extra tall-backed wheelchair too low resulting in it dragging on the floor. In an observation on 12/05/2024 at 12:38 9M Resident #9 was observed with the Foley catheter bag touching the floor. 4. Record review of Resident #2's face sheet, dated 12/06/2024, reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (condition that affects one side of the body usually caused by a stroke that can cause paralysis), a traumatic brain injury, and a cerebral infarction (stroke). Record review of Resident #2's Comprehensive Person-Centered Care Plan, undated, reflected that Resident #2 had a suprapubic catheter related to obstructive & reflux uropathy & BPH with no interventions related to preventing the catheter bag from dragging on the floor. Record review of Resident #2's quarterly MDS assessment, dated 9/28/2024, reflected a BIMS score of 13, indicating that the resident's cognition was intact. The MDS assessment further reflected that Resident #2 utilized an indwelling catheter. Record review of Resident #2's Order Summary Report, dated 12/06/2024, reflected an order which read, Keep urinary drainage bag below the level of the bladder at all times. In an observation on 12/03/2024 at 1:29 PM Resident #2's Foley catheter bag was observed to be dragging on the floor under his wheelchair while being assisted from the dining room back to his room. In an observation on 12/05/2024 at 8:58 AM Resident #2 was observed with the Foley catheter bag touching the floor under his wheelchair while in the communal hallway to the therapy gym. 5. Record review of the Face Sheet printed 12/06/2024 reflected Resident #49 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS dated [DATE], reflected Resident #49 had a BIMS summary score of 11, indicative of moderately impaired cognition. Resident #49 was coded as having an indwelling catheter. Active diagnoses included: obstructive uropathy [blockage of urinary flow], and cerebrovascular accident [loss of blood flow to part of the brain, stroke]. Record review of the Order Summary Report printed 12/06/2024 reflected Resident #49 had a physician's order for Foley catheter, 16 French [indicative of the size of the tubing] with 30 ml balloon [30 ml of fluid filled balloon holds the tubing inside the bladder] with an order date of 11/20/2024. Record review of the Care Plan printed 12/06/2024 reflected Resident #49 had a focus area of I have indwelling catheter related to obstructive and reflux uropathy and BPH ; with the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door. [CP did not address keeping the Foley catheter bag off the floor.] In an observation on 12/06/2024 at 10:20 AM Resident #49 was seated in his wheelchair with the Foley catheter attached to wheelchair, with the drainage bag making contact with the floor. In an interview on 12/03/2024 at 1:35 PM LVN B stated the Foley catheter bags should not drag on the floor as it could be a risk to the residents. LVN B stated Foley catheter bags should be under the wheelchair, but not to where they drag on floor. LVN B stated the bag could leak due to friction or be a source of infection . In an interview on 12/06/2024 at 11:07 AM LVN E stated the Foley catheter bag should be positioned on the wheelchair on the left side at the front, where there was a stabilizing bar that was good to hook the Foley Catheter. LVN E stated that when the Foley catheter was placed on the cross bar [underneath the seat of the wheelchair], the Foley catheter bag would slide down to the lowest point of the X and then touch the floor. LVN E stated that staff were trained that the Foley catheter bag should always be lower than the level of the bladder and not glide on the floor due to infection control. LVN E stated this information was trained in annual competencies and in-services frequently . In an interview on 12/06/2024 at 11:16 AM, the DON stated none of the current residents who had Foley catheters self-managed their Foley catheters or the drainage bag. The DON stated it was her expectation that staff ensure the Foley catheter bag was kept below the level of the residents' bladder and not touch the floor for infection control prevention. The DON stated this requirement was trained upon new hire on boarding, at annual competencies, and during in-servicing trainings as necessary. The DON stated that the staff assisting the resident with a Foley Catheter bag was responsible for ensuring that it was not touching the floor. The DON stated that any staff member who saw a Foley Catheter bag touching the floor should either self-correct or alert the appropriate care giver if that staff member was not a direct care giver such as a nurse, CNA, or other clinician. In an interview on 12/06/2024 at 11:38 AM Lead CNA G stated that Foley catheter bags should have covers for privacy, Foley catheter bags should be maintained at a level lower than the bladder, but not touch the floor due to infection control concerns. Lead CNA G stated that she or another lead trained new hires, and she recommended that the Foley catheter bag be hooked towards the front of the wheelchair, as the cross bar at the back and under the seat was too low and the bag could drag on the floor. Lead CNA G stated this procedure was trained upon at hire, at annual competency check offs, and as in-services PRN. Lead CNA G stated that she did random spot checks to ensure the Foley catheter bags were positioning correctly and if not, she would offer immediate counseling to fix it. Lead CNA G stated she was not aware that any Foley catheter bags were reported as touching the floor recently. In an interview on 12/06/2024 at 11:48 AM CNA H stated the Foley catheter drainage bag was always to be placed below the level of the resident's waist to prevent back flow. CNA H stated the Foley catheter bag should be hung on the side of the wheelchair, where it would not fall or drag on the floor. CNA H stated the Foley catheter bag could degrade and leak or could pick up germs from the floor. Review of policy entitled Catheter Care, Urinary, reviewed December 2023, reflected instructions under the heading Infection Control 2b. Be sure the catheter tubing and drainage bag are kept off the floor. Review of Lippincott procedures, Indwelling urinary catheter (Foley) care and management, revised 11/17/2024, accessed from https://procedures.lww.com/lnp/view.do?pId=4420099&hits=care,catheter,catheters,carefully&a=true&ad=false&q=catheter%20care, accessed on 12/05/2024, reflected under the heading Clinical Alert, instructions to keep the drainage bag below the level of the patient's bladder; however, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter associated urinary tract infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protect and promote the rights of the Resident, for 3 of 25 (Resident #215, Resident #42, Resident #214) residents reviewed for dignity, in that; 1. The facility failed to ask Resident #215 and Resident #42 if they wanted to wear a clothing protector around their neck to protect their clothes from getting dirty, while they had their meal. Resident #215 did not want to wear the clothing protector on 10/23/2023 and 10/25/2023 lunch. Resident #42 did not want to wear a clothing protector around her neck for 10/25/2023 lunch. 2. The facility failed to give Resident #214 an egg roll that she ordered and was looking forward to, for 10/25/2023 lunch. This failure placed residents at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: 1. A record review of Resident #215's admission record on 10/23/2023 revealed an admission date of 09/25/2023 with diagnoses which included cerebral infarction (stroke), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder, and cognitive communication deficit. A record review of Resident #215's MDS assessment dated [DATE] revealed Resident #215 had a BIMS score of 05/15 indicating severe mental cognition impairment. A record review of Resident #215's care plan dated 10/23/2023, revealed, focus of My resident rights will be respected and maintained through the review date. With an Intervention/Task of Dignity and respect: *be treated with dignity, courtesy, consideration, and respect . Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services . A record review of Resident #42's admission record revealed an admission date of 10/26/2023 with diagnoses which included major depressive disorder, cognitive communication deficit, and generalized anxiety disorder (mental health condition that causes fear, worry and a constant feeling of being overwhelmed). A record review of Resident #42's MDS assessment dated [DATE] revealed Resident #42 had a BIMS score of 13/15 indicating intact cognition. A record review of Resident #42's care plan dated 10/26/2023, revealed focus of My resident rights will be respected and maintained through the review date. With an Intervention/task of Dignity and respect: *be treated with dignity, courtesy, consideration, and respect . Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services . Observation on 10/23/2023 at 12:16 PM, out of 22 residents in the dining room for lunch, Resident #214 was observed with no maroon-colored clothing protector around her neck. Resident #214 reported on 10/23/2023 at 12:19 PM that she did not need the clothing protector. Resident #215 was wearing a clothing protector and was later interviewed. Observation on 10/25/23 at 12:23 PM revealed 23 residents in the dining room for lunch meal. 5 out of 23 residents were observed with no maroon-colored clothing protectors around their neck. Staff were observed asking if residents wanted a clothing protector or not. During an interview on 10/23/2023 at 12:32 PM with Resident #215, he revealed that he did not like the clothing protector around his neck. He reported that he doesn't want enemies and sometimes it's better not to say anything. He reported that staff put it on him without asking. During an interview on 10/25/2023 at 12:18 PM, Resident #42 blew a raspberry (made a sputtering noise by pressing the tongue and lips together) when asked if she liked the maroon-colored clothing protector around her neck. Resident #42 then revealed that she did not like the clothing protector because food still fell through it and she forgot to take it off sometimes. During an interview on 10/26/2023 starting at 5:35 PM, the DON revealed that staff are supposed to ask if the resident would like to wear a clothing protector. This would cause a resident to be embarrassed. The DON revealed that they do not want the residents to be treated differently by putting the clothing protector if they did not want it on. 2. A record review of Resident #214's admission record on 10/25/2023 revealed an initial admission date of 06/12/2023 and was re-admitted [DATE] with diagnoses which included generalized muscle weakness, abnormalities of gait and mobility, and other lack of coordination. A record review of Resident #214's MDS assessment dated [DATE] revealed Resident #214 had a BIMS score of 14/15 indicating intact cognition. A record review of Resident #214's care plan dated 10/25/2023, revealed, focus of My resident rights will be respected and maintained through the review date. With an Intervention/task of Dignity and respect: *be treated with dignity, courtesy, consideration, and respect . Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services . During an observation and an interview on 10/25/2023 at 1:08 PM, Resident #214 revealed that she did not receive an egg roll when her meal ticket revealed that she had an egg roll selected to receive for 10/25/2023 lunch. Resident reported that she was disappointed that she did not get her egg roll because she was looking forward to having it for lunch. During an interview on 10/25/2023 at 1:08 PM the RD confirmed that Resident #214's lunch meal tray ticket had an egg roll on her ticket and there was no egg roll on the plate. Resident #214 then confirmed with the RD that she did not receive an egg roll. During an interview on 10/25/2023 starting at 1:18 PM, the RD revealed that there were no more egg rolls available in the kitchen. The RD reported that he did not like it when there was not enough food for all of the trays. The RD further revealed that residents who did not receive their food requests was an issue because a lot of times residents looked forward to their meals. During an interview on 10/26/2023 starting at 5:35 PM, the DON revealed that she would feel upset and disappointed if she did not receive what she wanted at mealtime. During an interview on 10/26/23 at 6:40 PM, the ADMN revealed that he wanted to have the residents happy and fulfilled, so residents needed to get what they wanted to eat, when it was revealed that a resident did not receive an egg roll that she ordered. He further revealed that food was one of the pleasures that they provided for their residents as things get taken away from them as a part of life. A record review of the Resident Rights policy, reviewed December 2022, states Employees shall treat all residents with kindness, respect and dignity. And 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the assessments accurately reflected the resident's status for 1 of 29 residents (Resident #57) reviewed for resident assessments, in that: The facility failed to ensure Resident #57's discharge MDS, dated [DATE], was coded as a hospital discharge instead of a community discharge. This deficient practice could place residents at risk of not having their individually assessed needs met. The findings were: Record review of Resident #57's face sheet, dated 10/26/2023, revealed the resident was admitted to the facility on [DATE] with the diagnoses that included: end stage renal disease, vascular dementia without behavioral disturbance, and major depressive disorder. Record review of Resident #57's Quarterly MDS, 09/12/2023, revealed on A2100. Discharge status entered as 01. Community instead of 03. Acute Hospital. Record review of Resident #57's Progress Notes, dated 10/26/2023, note entered 09/12/2023 at 2:18 p.m., revealed As per family request resident to be sent to University [name of hospital] due to altered mental status. Further review of progress notes did not reveal resident returned from the hospital. During an interview and record review of Resident #57's discharge MDS on 10/26/2023 at 4:21 p.m., the MDS Coordinator confirmed discharge MDS was coded as community and needed to be acute hospital. The MDS Coordinator was unable to recall why it was coded incorrectly. She stated the potential harm to resident was mental harm because the record was not accurate. During an interview on 10/26/2023 at 6:39 p.m., the DON stated the MDS Coordinator was responsible for coding the MDS' but that she, as the DON, looked over the information and signed off on it. The DON stated she believed there was no potential harm to the resident because he was already in a higher level of care than a nursing home. During an interview on 10/26/2023 at 7:16 p.m., the Administrator stated the MDS Coordinator and BOM were ultimately responsible to ensure MDS' were coded correctly. The Administrator stated there was always a potential harm to the resident but none noted at this time. Record review of the facility's policy titled, MDS Correction, revised 12/2022, revealed, The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established processes for making corrections to the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one resident (Residents #43) out of 5 residents reviewed for medication administration, in that: The facility failed to ensure Resident #43 received Acetylcysteine [a medication to help thin and loosen mucus in the airways due to certain lung diseases], and Baclofen [a medication for the treatment of muscle spasms] on 10/25/2023 as ordered. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and result in a diminished quality of life. The findings include: Record review of the admission Record revealed Resident #43 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #43's primary reason for admission was for stroke [disruption of blood flow to the brain that causes brain cell death]. Other active diagnoses included hemiplegia/hemiparesis [slight weakness to paralysis on one side of the body], muscle weakness, abnormalities of gait and mobility, lack of coordination, and asthma. Resident #43 had a BIMS summary score of 14 indicative of intact cognition. Resident #43 received pain medication in the previous 5 days of the assessment. Record review of the Order Summary Report printed 10/25/2023 revealed Resident #43 had active physician orders for: physical therapy skilled services three times per week with an order date of 9/20/2023; skilled occupational therapy services three times per week with an order date of 9/21/2023; acetylcysteine oral capsule 500 milligram 1 capsule via PEG tube [percutaneous endoscopic gastrostomy tube allowing nutrition, fluids or medications into the stomach] one time a day with a start date of 9/11/2023; baclofen oral tablet 5 milligram 1 tablet by mouth two times a day with a start date of 10/11/2023. Record review of the Care Plan revealed Resident #43 had a focus area of altered respiratory status, with the associated intervention of administer medications as ordered with a start date of 5/12/2023. Resident #43 had a focus area of hemiplegia/hemiparesis with the associated intervention of give medications as ordered with a start date of 5/12/2023. Resident #43 had a focus area of pain related to impaired mobility with the associated intervention of administer analgesia as per orders; give before treatments or care with a start date of 5/12/2023. Record review of Medication Administration Record, printed 10/26/2023, revealed Resident #43's acetylcysteine and baclofen administrations for the 9:00 AM doses on 10/25/23 were coded as not administered 9 = Other/See Nurses Notes by LVN A. In an observation and interview on 10/25/2023 at 9:19 AM, LVN A prepared medications for Resident #43 that did not include the scheduled dose of acetylcysteine or baclofen. LVN A stated the medications were, currently, not available. LVN A stated acetylcysteine was ordered on 10/17/2023, which was before it ran out. LVN A stated baclofen was ordered on 10/22/2023 and was before it ran out. Resident #43 stated that the baclofen made therapy easier, and he (Resident #42) expressed he was glad that at least had the tramadol on board. LVN A stated she would order the medications again and hope they will be here soon. LVN A stated when there is only a few days left of the medication, that is when you send an electronic message from the MAR to the pharmacy to send a new card of medication. Record review of Medication Administration Record, printed 10/26/2023 at 3:56 PM, revealed Resident #43's acetylcysteine and baclofen administrations for the 9:00 PM dose on 10/25/23 and for the 9:00 AM dose on 10/26/2023 were coded as administered by scheduled nursing staff. In an interview on 10/26/2023 at 6:48 PM, the DON stated, everyone was made aware of the medications needing to be refiled. The DON stated Resident #43 received the medication as soon as it was received in the building. The DON stated the expectation is medications were ordered in a timely manner in order to manage the resident's pain. The DON stated she was not sure why the medication was not received sooner. The DON stated she would investigate further into the issue. The DON stated there could be potential harm to the resident because of his pain level not being managed either by him not being comfortable or in discomfort. Record review of Medication Administration General Guidelines dated 12/2022, revealed under the subheading Medication Administration, step 1.) Medications are administered in accordance with written orders of the prescriber. Record review of the topic Pain Management of the Clinical Programs Manual, undated, revealed, under step 6e.) Maintain prescribed levels; ensure medications are taken on time even if asymptomatic unless ordered PRN. Under step 9.) Utilize adjuvant medications for pain control, when appropriate, including but not limited to: .muscle relaxants for treatment of skeletal muscle pain.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 medication carts of 6 medication carts (Treatment Cart 300-hallway) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart 300-hallway was locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 10/25/2023 at 8:50 AM, the Treatment Cart on the 300-hallway was unlocked and unattended. The Treatment Cart contained prescription and over the counter medications related to skin and wound care. There were ambulatory residents and visitors in the immediate vicinity. Staff were seated at the 300-hallway nurses' station but could not see the Treatment Cart from their position. In an interview on 10/25/2023 at 8:54 AM, LVN D stated the Treatment Cart was her responsibility. LVN D stated she had been at the cart until just a few minutes prior preparing for the wound care practitioner to provide care to residents but had been called away by a co-worker for another, urgent task. LVN D stated she knew the Treatment Cart should not have been left unlocked and unattended before she left the area. LVN D stated the Treatment Cart had been left unlocked and unattended less than 5 minutes. LVN D ended the interview stating the wound care practitioner was waiting for her and she needed to attend to that task now. In an interview on 10/26/2023 at 6:46 PM, the DON stated she had been made aware the Treatment Cart was left unlocked and unattended. The DON explained that nurses would work on tasks together that required access to the Treatment Cart. The DON stated the primary nurse responsible for the Treatment Cart had stepped away while the wound care practitioner was still obtaining supplies from that Treatment Cart. The DON stated that the nurse with the keys is responsible for the security of the Treatment Cart. The DON stated the Treatment Cart contained items needed for the cleaning or treatment of skin issues, and if a resident had an allergy, or slipped and fell, or ingested something from the cart, there could be potential for harm to a resident. Record review of Storage of Medications dated 12/2022, revealed a policy statement of, store all drugs and biologicals in a safe, secure and orderly manner. Under the heading, Policy Interpretation and Implementation, step 7.) Compartments containing drugs and biologicals shall be locked when not in use .or otherwise potentially available to others.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 15 of 26 staff (ADMN, ADON, DM, AD, RN J, RN K, LVN D, LVN L, CNA M, CNA N, CNA O, RA P, Hskg Q, Recept R, MR S) reviewed for abuse and neglect, in that: The facility failed to implement their abuse policy when the ADMN, ADON, DM, AD, RN J, RN K, LVN D, LVN L, CNA M, CNA N, CNA O, RA P, Hskg Q, Recept R, MR S's annual EMR was not completed in the past year. This failure could place residents at risk for abuse and neglect. The findings were: Record review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property, reviewed 08/2017 which read 5. [ .] Screening: Potential employees will be screened, per federal &/or state regulation, [ .] Screening will consist of: [a] Inquiries into the State licensing authorities [b] Inquires into State nurse aide registry [ .]. 1. Record review of the Staff Roster, undated, revealed the ADMN was hired on 06/18/2021. Record review of the ADMN's staff records revealed the ADMN's last searched EMR, provided by the facility, was dated 10/24/2023. 2. Record review of the Staff Roster, undated, revealed the ADON was hired on 08/15/2022. Record review of the ADON's staff records revealed the ADON's last searched EMR, provided by the facility, was dated 07/28/2022. 3. Record review of the Staff Roster, undated, revealed the DM was hired on 09/09/2015. Record review of the DM's staff records revealed the DM's last searched EMR, provided by the facility, was dated 05/17/2022. 4. Record review of the Staff Roster, undated, revealed the AD was hired on 05/19/2021. Record review of the AD's staff records revealed the AD's last searched EMR, provided by the facility, was dated 05/24/2022. 5. Record review of the Staff Roster, undated, revealed the RN J was hired on 08/23/2022. Record review of the RN J's staff records revealed the RN J's last searched EMR, provided by the facility, was dated 08/18/2022. 6. Record review of the Staff Roster, undated, revealed the RN K was hired on 06/01/2021. Record review of the RN K's staff records revealed the RN K's last searched EMR, provided by the facility, was dated 05/24/2022. 7. Record review of the Staff Roster, undated, revealed the LVN D was hired on 10/28/2022. Record review of the LVN D's staff records revealed the LVN D's last searched EMR, provided by the facility, was dated 10/24/2022. 8. Record review of the Staff Roster, undated, revealed the LVN L was hired on 10/28/2022. Record review of the LVN L's staff records revealed the LVN L's last searched EMR, provided by the facility, was dated 10/24/2022. 9. Record review of the Staff Roster, undated, revealed the CNA M was hired on 02/09/2022. Record review of the CNA M 's staff records revealed the CNA M's last searched EMR, provided by the facility, was dated 02/04/2022. 10. Record review of the Staff Roster, undated, revealed the CNA N was hired on 05/18/2022. Record review of the CNA N 's staff records revealed the CNA N's last searched EMR, provided by the facility, was dated 05/11/2022. 11. Record review of the Staff Roster, undated, revealed the CNA O was hired on 11/24/2021. Record review of the CNA O 's staff records revealed the CNA O's last searched EMR, provided by the facility, was dated 05/04/2022. 12. Record review of the Staff Roster, undated, revealed the RA P was hired on 12/12/2017. Record review of the RA P's staff records revealed the RA P's last searched EMR, provided by the facility, was dated 05/17/2022. 13. Record review of the Staff Roster, undated, revealed the Hskg Q was hired on 05/24/2021. Record review of the Hskg Q 's staff records revealed the Hskg Q's last searched EMR, provided by the facility, was dated 05/24/2022. 14. Record review of the Staff Roster, undated, revealed the Recept R was hired on 06/03/2022. Record review of the Recept R's staff records revealed the Recept R's last searched EMR, provided by the facility, was dated 06/02/2022. 15. Record review of the Staff Roster, undated, revealed the MR S was hired on 07/14/2021. Record review of the MR S 's staff records revealed the MR S's last searched EMR, provided by the facility, was dated 10/24/2023. During an interview and record review, of EMR's still needed by several staff, on 10/26/2023 at 3:44 p.m., HR stated he was aware of the required annual EMR's but he was not aware that he needed to print them for the staff member's file. He stated the potential harm to residents depended on the staff member's background for abuse. During an interview and record review, of EMR's still needed by several staff, on 10/26/2023 at 6:34 p.m., the DON stated she was aware of the required annual EMR. She stated HR was who ran and looked up the information but the IDT staff were who ensured it was completed. The DON stated the potential harm to resident depended on what the EMR showed for that staff member's background. During an interview and record review, of training still needed by several staff, on 10/26/2023 at 7:14 p.m., the ADMN stated he was aware of the required EMR. He stated the Administration staff was who ensured it was completed. The ADMN stated the potential harm to a resident was if the staff member's records showed they should not be working in a nursing home because of a criminal history.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 25 residents (Resident #28, #29, and #37) for care plan revisions, in that: 1. The facility failed to ensure Resident #28's care plan was revised to indicate the residents change in code status. 2. The facility failed to ensure Resident #29's and Resident #37's care plan was revised to include tube feedings. These failures could place residents at risk of receiving inappropriate care. The findings include: 1. Record review of Resident #28's face sheet dated 10/24/2023 revealed an initial admission date of 09/11/2023 with a most recent admission of 10/03/2023 and diagnoses which included: acute posthemorrhagic anemia (acute blood loss anemia), gastrointestinal hemorrhage (bleeding from the gastrointestinal tract) and adult failure to thrive (insufficient weight gain, loss of appetite). Further review of Resident #28's face sheet, revealed under the section DNR. Record review of Resident #28's Quarterly MDS assessment, dated 10/09/2023, revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. Record review of Resident #28's care plan, last review date 10/10/2023, revealed I am a Full Code and If found absent of vital signs initiate CPR. Record review of Resident #28's electronic medical record Order Summary Report, Active Orders as of 10/24/2023, revealed an order dated 10/12/2023 for DNR. Record review of Resident #28's electronic clinical record revealed an OOH-DNR signed by Resident #28, dated 10/12/2023. 2. Record review of Resident #29's face sheet dated 10/23/2023 revealed an initial admission date of 08/08/2022 and diagnoses which included: senile degeneration of brain (cognitive decline, particularly memory loss), muscle wasting and atrophy (thinning or lose of muscle tissue), and dysphagia (difficulty in swallowing food or liquid) following cerebrovascular disease (conditions that impact the blood vessels in your brain). Record review of Resident #29's MDS assessment, dated 10/15/2022, revealed the resident's BIMS score was 13/15, which indicated intact cognition. Further review of the MDS assessment indicated Resident #29 had received tube feedings prior to and while being a resident, receiving 51% or more of total calories and 501 cc/day or more through tube feedings. Record review of Resident #29's care plan, dated 10/23/2023, revealed a Focus of (Resident #29) require tube feeding and also has Regular diet, 4)texture, 0) liquids when family request or therapy (has waiver), revised on 11/17/2022 with an Intervention/Task of FiberSource HN 60 mL/hour x22=1320mL formula/1584kcals/71gr. Protein/1063mL free water. 150ml flushes q6 hours via g-tube. Record review of Resident #29's electronic medical record Order Summary Report, Active Orders as of 10/23/2023, revealed an order dated 07/31/2023 for FiberSource HN 70mL/hour x 22=1540mL formula/1848kcals/81 gr. Protein/1212mL free water. 150ml flushes q6 hours via g-tube. Record review of Resident #37's face sheet dated 10/26/2023 revealed an initial admission date of 09/09/2023 and diagnoses which included: adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, gastrostomy status (artificial opening to the stomach), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #37's MDS assessment, dated 10/02/2023, revealed the resident could not have a BIMS conducted. The Staff Assessment for Mental Status revealed resident had both short- and long-term memory problems. It was further revealed that resident had severely impaired cognitive skills for decision making. Further review of the MDS assessment indicated Resident #37 had received tube feedings during the entire last 7 days, receiving 51% or more of total calories and 501 cc/day or more through tube feedings. Record review of Resident #37's care plan, dated 10/23/2023, revealed a Focus of I require tube feeding r/t dementia and AFTT with pocketing food behavior, initiated 09/11/2023, with no specific tube feeding orders. Record review of Resident #37's electronic medical record Order Summary Report, Active Orders as of 10/23/2023, revealed an order dated 10/10/2023 for Jevity 1.5 @65cc/hr for 22hrs/day. Record Review of HPSI (acronym not found) Policy & Procedure Manual, Guidelines for the Food and Nutrition Services Department, Copyright 2017 revised, revealed Section H. Nutrition Care IV. Nutrition Support and Interventions .B. Total Enteral Feeding (TEN) Procedure: 7. The Registered Dietitian Nutritionist (RDN) reviews residents on TEN monthly unless otherwise indicated by a resident's condition All progress notes are placed in the medical record and the care plan is updated to current condition of resident. During an interview on 10/26/23 starting at 4:24 PM, the MDS coordinator revealed that Resident #28 is DNR but confirmed that Resident #28's care plan stated that resident was a Full Code. The MDS Coordinator reported that if the care plan was not updated to a code status of Full Code, that consequences could be catastrophic. The MDS coordinator revealed that she looked over care plans to make sure they are updated. Other staff, like the DON and ADON, helped update care plans too. During an interview on 10/26/23 at 5:35 PM, the DON revealed that Resident #28 is coded DNR but the care plan revealed that the resident's code status is Full Code. During an interview on 10/26/2023 starting at 5:35 PM, the DON confirmed that the Order Summary Report printed on 10/23/2023 for Resident #29 did not have the updated tube feeding order, which could cause the resident to not get enough calories and protein which could affect their wound healing and weight. During an interview on 10/26/23 at 7:00 PM, the ADMN revealed that care plans existed to know how to take care of residents and meet their needs. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, reviewed December 2022, revealed, 13. Assessments of residents are on-going and care plans are revised as information about the residents and residents' condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, failed to provide a therapeutic diet which was prescribed by the attending physician for two residents (Resident #4 and Resident #7) out of 8 residents reviewed for therapeutic diets, in that: 1. The facility did not serve Resident #4 a minced & moist diet and a magic cup for lunch as prescribed by the attending physician. 2. The facility did not serve Resident #7 soft & bite sized potatoes & onions as was reflected in his 10/24/2023 lunch meal tray ticket and the recipe. The facility did not change Resident #7's diet on for 10/24/2023 lunch from a soft & bite sized diet to a minced & moist diet as was revealed as a doctor's order on 10/23/2023. These failures could place residents who received food from the kitchen at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. The findings were: 1. A record review of Resident #4's face sheet on 10/25/2023 revealed an initial admission date of 05/10/2022 and was readmitted [DATE] with diagnoses which included aphasia (loss or impairment of the power to use or comprehend words usually resulting from brain damage) and dysphagia (difficulty in swallowing food or liquid) following cerebral infarction (stroke), muscle wasting and atrophy, altered mental status. A record review of Resident #4's MDS assessment dated [DATE] revealed BIMS should not be conducted for Resident #4 due to cognitive skills for daily decision-making being severely impaired and there are short-term and long-term memory problems present. A record review of Resident #4's care plan dated 10/25/2023, revealed, focus of I have a nutritional problem or potential for nutritional problem r/t dysphagia with Interventions/Tasks of Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. A record review of Resident #4's Doctor's order revealed resident had an Regular diet Minced &Moist texture, Thin . Ice cream and soup with lunch and dinner with an order date of 06/14/2023. Record review of HPSI (unable to find acronym meaning but it's defined as an Avendra Group Company) Diet manual, copyright 2023 revised HPSI provides five levels of mechanically altered foods: Mechanical Soft/Ground (mastication issues), Dysphagia Diets (difficulty in swallowing): Puree (Level 4); Minced & Moist (Level 5 - MM5); Soft & Bite Sized (Level 6 - SB6), EC7 (Level 7). The HPSI Dysphagia Diets and Easy to Chew EC7 are following the guidelines of the International Dysphagia Diet Standardization Initiative (IDDSI framework). The facility used pureed, minced & moist, soft & bite sized, and regular diets. Record review of HPSI Diet manual, copyright 2023 revised, revealed Minced & Moist diet is defined as: A diet used in the management of dysphagia with the food texture prepared as minced and moist. The food can be scooped and shaped into a ball shape and the size of the lump must be no greater than 4 mm x 15 mm (approximately 1/8-inch x 1/2-inch pieces) for adults. Biting is not required with this diet and only minimal chewing is needed. The foods are easily mashed with a fork and have no separate thin liquids. Record review of HPSI Diet manual, copyright 2023 revised, revealed, Soft & Bite Sized diet is defined as: A diet used in the dietary management of dysphagia with the food texture to be prepared as soft, tender, and moist with no separate thin liquid. The particle size of the food should be no greater than 15 mm x 15 mm (approximately 1/2 x 1/2 pieces) for adults. Biting is not required, but chewing is required. The diet does require the resident to have adequate tongue force to move the bolus to prevent aspiration. And All prepared food should be tested for texture and piece size before service. During an observation and a combined interview on 10/25/2023 with the RD and Resident #4's significant other, starting at 12:58 PM, Resident #4 received a soft and bite sized meal instead of a minced and moist meal even though her 10/25/23 lunch meal tray ticket reflected a minced and moist diet. Meats were long and rectangular (with a length greater than ½-inch) instead of small and cubed as was reflected in the recipe. This observation was confirmed with the RD. Resident #4 also did not receive a magic cup that was reflected on her lunch meal tray ticket. This observation was also confirmed with the RD. Resident #4's significant other verified the lunch meal tray did not have a magic cup. The RD did try to take the meal from Resident #4 to give her the correct textured diet. However, Resident #4's significant other stopped the RD because the significant other did not want Resident #4 to receive the minced and moist meal. The RD identified that this can be a choking hazard. During an interview on 10/26/2023 at 06:40 PM, the ADMN revealed that if a resident did not receive a magic cup, they could lose extra calories and be at risk for weight loss. 2. A record review of Resident #7's admission record on 10/24/2023 revealed an admission date of 10/05/2023 with diagnoses which included altered mental status, cognitive communication deficit, dysphagia (difficulty in swallowing food or liquid), and lack of coordination. A record review of Resident #7's MDS assessment dated [DATE] showed no BIMS being performed. A record review of Resident #7's care plan dated 10/24/2023, revealed, focus of I have a nutritional problem or potential for nutritional problem r/t MECHANICAL DIET with Interventions/Tasks that include Provide and serve diet as ordered. A record review of Resident #7's Doctor's order revealed resident had an NAS/CC diet Minced &Moist texture, Nectar consistency, level 5/no puree items please with an order date of 10/23/2023. A record review of Resident #7's 10/25/2023 lunch meal tray ticket revealed Diet was Soft & Bite Sized CC NAS. Record review of Week 2 menu revealed a side of potatoes & onions for Tuesday lunch. Record review for recipe of potatoes & onions revealed Soft & Bite sized should be chop cooked regular portions. Make sure all particles are no more than 15 millimeters x 15 millimeters (approx ½ in. x ½ in.) in size. During an interview on 10/24/2023 at 1:15 PM, CNA J reported that the potatoes & onions side dish for Resident #7's lunch meal looked like pureed mashed potatoes. During an interview and observation on 10/24/2023 at 1:17 PM, the DM reported the potatoes & onions side dish were mashed potatoes for Resident #7's meal. Upon review of the 10/24/2023 lunch meal tray ticket, an updated lunch meal tray ticket should have been printed; the DM revealed that Resident #7's diet should have been NAS/CC Minced & Moist. The DM further revealed that the ST T had probably given her a pink communication slip and the system to print tray tickets was not updated. The DM further revealed that after the ST T updated a diet, this should be updated in between meal services. During an interview on 10/24/2023 at 4:44 PM, the ST T reported that the lunch tray ticket for Resident #7 appeared to not be updated in time for 10/24/2023 lunch. The ST T revealed that if the tray tickets were already printed out that the update would need to be handwritten on the ticket that was printed out. The ST T further revealed that if a downgraded diet was not updated in time, a resident is at risk for choking. Also, if an upgraded diet was not updated in time, the resident could possibly not be satisfied with the meal. During an interview on 10/26/23 at 5:35 PM, the DON revealed that a resident should not receive the wrong textured diet because the nurse should check and correct it before passing it to the resident. If a resident received an upgraded diet, like a regular diet, and they were supposed to receive a doctor prescribed downgraded diet, like a pureed diet, resident could aspirate, may not be able to chew, and decrease nutrient intake. If a resident received a downgraded diet instead of their doctor prescribed upgraded diet, a resident could not want to eat their meal. The DON also revealed that adding a magic cup to meals would be needed for wound healing and to prevent weight loss. Record review of the HPSI diet manual and Record Review of HPSI Policy and Procedures, copyright 2017 revised, defines therapeutic diets as, Therapeutic Diets as well as texture modifications for diets must be prescribed by the attending physician . Fortified foods are considered a therapeutic diet. Record Review of HPSI Policies and Procedures revealed Section D: Food Production . IV. Food Service Temperature Control .N. Textures . 1. All foods will be prepared in the texture/viscosity modification-as needed by each resident's individual requirement 2. Standard texture modifications include chopped, ground, pureed 5. Standards of preparation must follow the most current guidelines for the preparation of textured modified foods for those with swallowing disorders. And, Section E: Dining Service III. Tray Cards . Policy: A tray card will be issued for each resident . Procedure: 1. Upon receipt of a diet communication slip from nursing containing a new or changed diet order, the Nutrition Services staff will prepare a tray card for the resident 4. If computer generated tray cards are used, a new set will be printed for each meal. And, XI. Accurate Diet Service . Policy: Each resident will receive the proper diet as prescribed by their physician. Procedure: 1. Before each meal service, a Food & Nutrition Services Department employee will check the tray cards with a master list to assure the correct diet order, consistency order and liquid consistency order are on the card. 2. Prior to serving the tray, the nurse aide must check the tray card to assure that the correct tray is being served to the resident. If there is doubt, the charge nurse should be notified and the chart checked for the current physician's order.

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 1 of 1 kitchen, in that: 1. There were 3 storage containers of prepared food in two separate refrigerators that were not properly sealed. 2. DA K wore jewelry with dangling charms on her wrist while engaged in food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 10/23/2023 at 9:52 AM in one of the refrigerators revealed an opened clear bag (the manufacturer's bag that would be inside of the product's box) of French fries. In the next refrigerator there was an opened clear, plastic bag of sausage patties. This exposed the contents of the bags to the ambient air in the cooler and potential contamination by pathogens and bacteria. The DM then went to get a Ziploc bag to put the French fries in, to seal it. Observation on 10/25/2023 at 11:31 AM, revealed an opened Ziploc bag of waffles for 10/25/2023 breakfast, which was confirmed by the DM. Interview on 10/23/2023, after above observation, the DM revealed the [NAME] E forgot to keep the fries sealed while preparing them as the lunch alternative for 10/23/2023. This was confirmed by [NAME] E, during this interview. The opened package of sausages was for 10/23/2023 breakfast. The DM further revealed all dietary employees were trained to make sure that there were not any open bags in the fridge/freezer. Interview on 10/25/2023 at 11:31 AM, the RD revealed that the Ziploc bags do open and it is a problem. The RD revealed that the products could possibly be put in storage containers or have zip ties on them. In a combined interview on 10/25/2023 at 11:36 AM, the DM and the RD agreed that exposed food products could cause contamination and even freezer burn. They agreed that they strived for minimal error. 2. Observation on 10/25/2023 at 11:41 AM revealed DA K wearing a bracelet with dangling charms while preparing for 10/25/2023 lunch. Interview with the DM on 10/25/2023 at 11:42 AM revealed that DA K is trained on not wearing the bracelet, but DA K is new and still being trained. DA K confirmed the DM's statement and revealed that she understood the risk of contamination. Record review of facility policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices reflected Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illnesses . 13. Jewelry will be kept to a minimum and hand jewelry (e.g., rings) will be kept covered with gloves during food handling. Record Review of HPSI Policy and Procedures, Copyright revised 2017, revealed Section C: Cost Containment . IV. Food Storage All opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to have an accurate assessment for one resident (Resident #3) out of 12 residents reviewed for accurate assessments in that: Resident #3 received oxygen therapy that was not reflected on her MDS assessment. This deficient practice could place residents at risk of missed care. The findings were: Record review of Resident #3's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat) and cardiac pacemaker (device attached to the heart that generates electrical impulses to the heart to help it pump properly). Record review of Resident #3's MDS, an admission assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact; and under Section O, it was not checked Resident #3 received oxygen. Record review of Resident #3's electronic physician orders from 06/01/22 to 09/07/22 revealed there was no order for Resident #3 to receive oxygen. Record review of Resident #3's care plans, initiated 06/01/22 and revised on 06/27/22, revealed there was no care plan for oxygen therapy. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/01/22 indicated oxygen had been administered to the resident at 3 LPM via nasal cannula (a tubing device used to deliver supplemental oxygen that has two prongs at an end which are inserted into the nostrils). Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/01/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/05/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/06/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed nurses progress note by LVN C dated 06/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Observation on 09/06/22 at 10:40 a.m. revealed Resident #3 was sitting in a wheelchair in her room with an oxygen concentrator behind the resident that was not in operation. In an interview on 09/06/22 at 01:49 p.m., Resident #3 stated she used the oxygen at night when she was sleeping and removed the oxygen in the morning. Observation on 09/08/22 at 5:44 a.m. revealed Resident #3 was lying in bed and received oxygen via nasal cannula at 2 LPM. In an interview on 09/08/22 at 6:08 a.m., LVN A stated the nurse would place the nasal cannula on Resident #3 at night to administer oxygen at 2 LPM per the resident's request. LVN A stated Resident #3 needed the oxygen at night when she was first admitted ; the resident's condition improved, and she no longer needed the oxygen, but the resident wanted to have it on at night. In an interview on 09/08/22 at 8:58 a.m., LVN C stated Resident #3 received oxygen continuously when she was admitted to the facility, but the resident weaned herself off the oxygen and only used it at night. In an interview on 09/08/22 at 9:07 a.m., MDS Nurse stated she worked in the facility for only two weeks. The MDS Nurse reviewed Resident #3's nurse's notes for 6/6/22 and 6/7/22, stated it was noted Resident #3 received oxygen at 2 LPM via nasal cannula. The MDS Nurse reviewed Resident #3's admission MDS dated [DATE] and stated it was not coded for oxygen and should had been coded to indicate Resident #3 received oxygen since the nursing progress notes indicated she received oxygen. The MDS Nurse stated the risk of not having the MDS coded correctly could result in an inaccurate assessment and which did not reflect the resident's status. The MDS Nurse stated if the oxygen had been coded on the MDS then it would have triggered a care plan to have been completed for oxygen. In an interview on 09/08/22 at 3:25 p.m. the DON stated the facility would have interdisciplinary team meetings to review care plans to ensure their accuracy along with the MDS. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated the clinical leadership was responsible to ensure the residents' MDS assessments were accurate. Record review of CMS' RAI (Resident Assessment Instrument) Manual 3.0 User's Manual, October 2019, page O-1 to O-3, revealed the treatments, procedures and programs listed in Section O, could have a profound effect on an individual's health status, self-image, dignity, and quality of life. Under Steps for Assessment was 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period .Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia [low level of oxygen in the blood] . Record review of the policy MDS Error Correction, revised September 2010, revealed The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established processes for making corrections to the MDS. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for the resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 12 residents (Residents #3) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan that addressed Resident #3's use of oxygen. This deficient practice could place residents at risk for not receiving the appropriate care and services needed to maintain optimal health. The findings were: Record review of Resident #3's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat) and cardiac pacemaker (device attached to the heart that generates electrical impulses to the heart to help it pump properly). Record review of Resident #3's care plans, initiated 06/01/22 and revised on 06/27/22, revealed there was no care plan for oxygen therapy. Record review of Resident #3's MDS, an admission assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact; and under Section O, it was not checked Resident #3 received oxygen. Record review of Resident #3's electronic physician orders from 06/01/22 to 09/07/22 revealed there was no order for Resident #3 to receive oxygen. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/01/22 indicated oxygen had been administered to the resident at 3 LPM via nasal cannula (a tubing device used to deliver supplemental oxygen that has two prongs at an end which are inserted into the nostrils). Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/01/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/05/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/06/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed nurses progress note by LVN C dated 06/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Observation on 09/06/22 at 10:40 a.m. revealed Resident #3 was sitting in a wheelchair in her room with an oxygen concentrator behind the resident that was not in operation. In an interview on 09/06/22 at 01:49 p.m., Resident #3 stated she used the oxygen at night when she was sleeping and removed the oxygen in the morning. Observation on 09/08/22 at 5:44 a.m. revealed Resident #3 was lying in bed and received oxygen via nasal cannula at 2 LPM. In an interview on 09/08/22 at 6:08 a.m., LVN A stated the nurse would place the nasal cannula on Resident #3 at night to administer oxygen at 2 LPM per the resident's request. LVN A stated Resident #3 needed the oxygen at night when she was first admitted . She stated the resident's condition improved, and she no longer needed the oxygen, but the resident wanted to have it on at night. In an interview on 09/08/22 at 8:58 a.m., LVN C stated Resident #3 received oxygen continuously when she was admitted to the facility, but the resident weaned herself off the oxygen and only used it at night. In an interview on 09/08/22 at 9:07 a.m., MDS Nurse stated she worked in the facility for only two weeks. The MDS Nurse reviewed Resident #3's nurse's notes for 6/6/22 and 6/7/22, stated it was noted Resident #3 received oxygen at 2 LPM via nasal cannula. The MDS Nurse reviewed Resident #3's admission MDS dated [DATE] and stated it was not coded for oxygen and should had been coded to indicate Resident #3 received oxygen. The MDS Nurse stated the risk of not having the MDS coded correctly could result in an inaccurate assessment which did not reflect the resident's status. The MDS Nurse stated if the oxygen had been coded on the MDS then it would have triggered a care plan to be completed for oxygen. The MDS Nurse reviewed Resident #3's care plans and stated she did not see a care plan for oxygen. The MDS Nurse stated the risk of not having a care plan was that it would not capture the plan of care for the resident. In an interview on 09/08/22 at 3:25 p.m. the DON stated the facility would have interdisciplinary team meetings to review care plans to ensure their accuracy. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated the clinical leadership was responsible to ensure the residents' care plans were accurate. Review of the facility policy Care Plans, Comprehensive Person-Centered, revised December 2021, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each residents .1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to ensure that one (Resident #82) of one resident reviewed for urinary catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to ensure Resident #82 had an order to self-catheterize his intermittent urinary catheter. This deficient practice could place residents at risk for infection and not receiving services as needed. The findings were: Record review of Resident #82's face sheet, dated 09/08/22, revealed he was admitted to the facility on [DATE] with diagnoses which included retention of urine (inability to empty urine from the bladder). Record review of Resident #82's Hospital Discharge summary, dated [DATE], revealed 8. Chronic urinary retention with self-catheterization .self caths [catheterization (a tube inserted into the urinary bladder via the urethra which allows urine to drain from the bladder)] at home. Record review of Resident #82's consolidated electronic Physician Orders, dated 09/08/22, revealed there was no order for self-catheterization of a urinary catheter. Record review of Resident #82's MDS, an admission assessment dated [DATE], revealed his BIMS score was 15 out of 15, indication his cognitive skills for daily decision making was intact; and under Section H, it was checked indicating Resident #82 had an indwelling catheter. Record review of Resident #82's clinical record revealed a nurses' progress note by LVN H dated 08/29/22 which noted res Rresident #82] self [urinary] caths [catheterization] for urinary retention . Record review of Resident #82's clinical record revealed a nurses' progress note by RN G dated 08/29/22 which noted Resident #82 was self [urinary] cath [catheterization] every 4/6 [four to six] hours . Record review of Resident #82's clinical record revealed a nurses' progress note by RN F dated 08/31/22 which noted Resident #82 was self [urinary] cathing [catheterization]. Record review of Resident #82's clinical record revealed a nurses' progress note by RN E dated 09/04/22 which noted Resident #82 was self [urinary] cathing [catheterization]. Record review of Resident #82's clinical record revealed a nurses' progress note by LVN B dated 09/05/22 which noted Resident #82 continues with self [urinary] catheterization. Record review of Resident #82's clinical record revealed a nurses' progress note by LVN A dated 09/06/22 which noted Resident #82 continues with self [urinary] catherization. In an interview on 09/06/22 at 2:56 p.m., Resident #82 stated he performed intermittent urinary self-catheterization on himself. In an interview on 09/08/22 at 3:09 p.m., LVN C stated the facility provided Resident #82 with the urinary catheter supplies he needed for urinary self-catheterization. The LVN stated the nurse would assist Resident #82 to the bathroom where the resident would perform the urinary self-catheterization under the supervision of the nurse. LVN C reviewed Resident #82's electronic clinical record and stated she did not see an order for the resident to perform intermittent urinary self-catheterization. In an interview on 09/08/22 at 3:25 p.m., the DON stated if a resident was performing urinary self-catheterization he would expect an order for the self-catheterization and an assessment of the resident's ability to do the task. The DON reviewed Resident #82's electronic clinical record, and stated he did not see an order for urinary self-catheterization. The DON stated the risk of not having the order could result in urinary retention if the resident became incapacitated. The DON stated to ensure the orders were accurate the nurse would read back the order to the physician when the nurse received an order. The DON stated the physicians could review their residents' orders via electronic remote review to ensure they were accurate. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated the clinical leadership was responsible to ensure the residents' orders were accurate. Record review of the facility policy Male Intermittent Self-Catheterization (ISC) revealed Intermittent self-catheterization is a way to empty your bladder using a catheter when your bladder does not empty completely or it does not empty at all. It is the policy of this facility to ensure that any resident who chooses to self-catheterize understands the process and has been identified as safe to do so. Record review of the policy Medication Orders, revised November 2014, revealed The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .2. A current list of orders must be maintained in chronological order 6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. Record review of CMS 672 Resident Census and Conditions of Residents, completed by the facility on 9/6/22, indicated there was one resident in the facility with an indwelling or external catheter. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #3) reviewed for respiratory therapy, in that: The facility failed to ensure Resident #3 had a physician order for oxygen before providing the resident oxygen. This deficient practice could place residents at risk for inadequate or inappropriate amounts of oxygen delivery and lack of appropriate respiratory care. The findings were: Record review of Resident #3's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat) and cardiac pacemaker (device attached to the heart that generates electrical impulses to the heart to help it pump properly). Record review of Resident #3's MDS, an admission assessment dated [DATE], revealed her BIMS score was 14 out of 15, indication her cognitive skills for daily decision making were intact; and under Section O, it was not checked Resident #3 received oxygen. Record review of Resident #3's care plans, initiated 06/01/22 and revised on 06/27/22, revealed there was no care plan for oxygen therapy. Record review of Resident #3's electronic physician orders from 06/01/22 to 09/07/22 revealed there was no order for Resident #3 to receive oxygen. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/01/22 indicated oxygen had been administered to the resident at 3 LPM via nasal cannula (a tubing device used to deliver supplemental oxygen that has two prongs at an end which are inserted into the nostrils). Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/01/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/04/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN B dated 06/05/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed a nurses' progress note by LVN A dated 06/06/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed nurses progress note by LVN C dated 06/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Record review of Resident #3's clinical record revealed nurses progress note by LVN A dated 09/07/22 indicated oxygen had been administered to the resident at 2 LPM via nasal cannula. Observation on 09/06/22 at 10:40 a.m. revealed Resident #3 was sitting in a wheelchair in her room with an oxygen concentrator behind the resident that was not in operation. In an interview on 09/06/22 at 01:49 p.m., Resident #3 stated she used the oxygen at night when she was sleeping and removed the oxygen in the morning. Observation on 09/08/22 at 5:44 a.m. revealed Resident #3 was lying in bed and received oxygen via nasal cannula at 2 LPM. In an interview on 09/08/22 at 6:08 a.m., LVN A stated the nurse would place the nasal cannula on Resident #3 at night to administer oxygen at 2 LPM per the resident's request. LVN A stated Resident #3 needed the oxygen at night when she was first admitted ; the resident's condition improved, and she no longer needed the oxygen, but the resident wanted to have it on at night. LVN A stated Resident #3's oxygen blood levels were within normal limits without the oxygen. In an interview on 09/08/22 at 8:58 a.m., LVN C stated Resident #3 had received oxygen continuously when she was admitted to the facility, but the resident weaned herself off the oxygen and only used it at night. LVN C reviewed Resident #3's electronic clinical record for a physician's order for oxygen, stated she did not see a physician's order for the oxygen. LVN C reviewed Resident #3's discontinued physician orders and stated she did not see any orders for oxygen. LVN C stated there should had been an order for the oxygen. LVN C stated the previous DON would enter all the admission orders for new residents but now the floor nurses entered the admission orders for newly admitted residents. In an interview on 09/08/22 at 9:07 a.m., after the MDS Nurse reviewed Resident #3's nurse's notes from 6/6/22 to 6/7/22, she stated it was noted Resident #3 received oxygen at 2 LPM via nasal cannula. The MDS Nurse stated the risk of not having a physician order for oxygen could result in a significant risk to the resident as the resident could receive too little or too much oxygen than was needed. In an interview on 09/08/22 at 3:25 p.m. the DON stated residents who received oxygen should have an order for oxygen. The DON stated to ensure the orders were accurate the nurse would read back the order to the physician when the nurse received an order. The DON stated the physicians could review their residents' orders via electronical remote review to ensure they were accurate. In an interview on 09/08/22 at 3:41 p.m. the Administrator stated residents who received oxygen via nasal cannula should have a physician order for the oxygen. The Administrator stated the risk of not having an order for the oxygen would depend on if the resident received oxygen continuous or as needed and the rate the oxygen was administered. The Administrator stated the clinical leadership was responsible to ensure the residents' orders were accurate. Record review of the policy Medication Orders, revised November 2014, revealed The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .2. A current list of orders must be maintained in chronological order .3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. Record review of the policy Oxygen Administration, revised October 2018, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Record review of CMS 672 Resident Census and Conditions of Residents, completed by the facility on 09/06/22, indicated there were no residents in the facility who received respiratory treatment [oxygen]. .