**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 care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 22 residents (Resident #1) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1's diagnosis of Chronic combined systolic and diastolic congestive Heart Failure (heart does not pump blood adequately causing cough, shortness of breath, difficulty breathing, swelling, chest pain, weight gain, tiredness, and weakness). This failure could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #1's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility initially on 4/25/16 and re-admitted on [DATE]. Resident #1 had diagnoses of hypokalemia (low potassium), hypertension (high blood pressure), chronic combined systolic and diastolic heart failure. Record review of Resident #1's annual MDS assessment dated [DATE] revealed she had a BIMS of 10, which indicated she had moderate cognitive. The MDS indicated Resident #1 required total to maximum assistance for most ADLs. The MDS indicated Resident #1 had diagnoses of heart failure and hypertension. The MDS indicated Resident #1 had shortness of breath when lying flat. The MDS did not indicate Resident #1 was receiving a diuretic medication (used to pull extra fluid from body with increased urination). Record review of Resident #1's Physician Orders dated June 2024 revealed the following orders: * Torsemide 20 mg by mouth daily as needed, hold for blood pressure less than 100/60 or heart rate less than 60 for chronic combined systolic and diastolic heart failure with a start date of 3/1/24 *Torsemide 20 mg by mouth daily, hold for blood pressure less than 100/60 or heart rate less than 60 for chronic combined systolic and diastolic heart failure with a start date of 3/1/24. Record review of Resident #1's care plan dated 6/26/24 revealed she had hypertension and took a diuretic, but the care plan did not indicate Resident #1 had heart failure. Record review of Resident #1's Departmental Notes dated 6/11/24 indicated resident had a chest x-ray and new orders were to add torsemide 20 mg at 3:00 PM times five days in addition to the 20 mg every morning she was already taking. On 6/20/24, Resident #1 continued to have loose congestion and new orders received to increase Torsemide to twice daily for three days. During an observation and interview on 6/24/24 at 11:07 AM, Resident #1 was lying in bed. Resident #1 said the staff took good care of her and she did not have any concerns with her care. Resident#1 had a wet sounding rattle while breathing. During an interview on 6/26/24 at 2:07 PM, the ADON said he was responsible for ensuring the care plans were accurate and included everything needed after the assessments were complete and updated the care plans as needed. The ADON said the purpose of the care plan was to guide the resident's care. The ADON said things such as wounds, risks dehydration, code status, hospice, weight loss, things that could affect disease processes, and congestive heart failure to monitor for edema (swelling) should be included in the resident's care plan. The ADON said if he caught that congestive heart failure was not on care plan during his review, he would add it. The ADON said congestive heart failure was not on Resident #1's care plan and it should have been included. The ADON said if the resident did not have a care plan for congestive heart failure, the resident could go into fluid overload, have respiratory issues, and could lead to death. The ADON said by not having a care plan for an active disease process, it could lead to an exacerbation of the disease process and be detrimental to the resident. During an interview on 6/26/24 at 2:16 PM, the DON she said the interdisciplinary team consisting of the Social Worker, DON, ADON, Activities Directory, Dietary Manager, and MDS Coordinators were all part of the care planning process. The DON said mostly the ADON was responsible for ensuring the care plans included all pertinent information. The DON said the purpose of the care plan was so staff would know how to take care of the resident and to individualize the resident's care. The DON said congestive heart failure was a diagnosis that should be included in the care plan if the resident was taking a medication for it. The DON said if the care plan did not have all pertinent information, then staff that did not know the resident, would not know how to take care of them. During an interview on 6/26/24 at 2:45 PM, the ADM said the purpose of the care plan was to give a clear picture of the resident and how the staff was to best care for the resident. The ADM said the staff may not know how to address the resident's care if there was not a care plan. The ADM said she would expect the care plans to include pertinent resident information such as CHF. Record review of the facility's policy dated revised March of 2022 and titled Care Plans, Comprehensive Person-Centered, revealed . a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs were developed and implemented for each resident . comprehensive, person-centered care plan would . describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflected currently recognized standards of practice for problem area and conditions . care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . assessments of residents were ongoing and care plans were revised as information about the residents and the resident's conditions change .

**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 received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 7 residents who were reviewed for quality of care. (Resident #77) 1. The facility failed to ensure Resident #77 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 77 had proper catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care. Findings included: 1. Record review of Resident #77's face sheet dated 6/24/24 indicated Resident #77 was a [AGE] year old female and admitted to the facility initially on 4/17/24 and re-admitted on [DATE] with diagnoses including Unspecified dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), UTI (urinary tract infection) site not specified, other acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and urine retention. Record review of Resident #77's quarterly MDS assessment dated [DATE] indicated Resident #77 was usually understood and understood others. The MDS indicated Resident #77 had a BIMS score of 13 which indicated her cognition was intact. Resident #77 was maximal assistance on staff for toileting hygiene. The MDS indicated Resident #77 had an indwelling catheter (urinary catheter) and was always continent of bowel. Record review of Resident #77's care plan dated 4/18/2024 indicated she had a diagnosis of retention of urine and a failed removal of urinary catheter on 5/28/24. She had a current UTI. She was on enhanced barrier precautions with interventions of gloves and gown should be donned (put on) if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bathing, or other high contact activity. Record review of Resident #77's Order Summary Report dated 5/09/24 revealed an order to check the Foley catheter two times daily for correct placement, leaking and anchored to the skin. Staff should ensure her catheter bag is placed in a dignity bag when out of room. Resident #77's orders revealed there was no order noted related to Resident #77's urinary Foley catheter size and amount of fluid in the bulb. During an interview on 6/25/24 at 10:15 AM, the DON was notified Resident #77's urinary catheter size and bulb orders were not noted in her chart. The DON said she would find the orders. During an interview on 6/25/24 at 2:30 PM the DON stated Resident #77's urinary catheter size and bulb orders were not in the resident's chart. During an observation and interview on 6/26/24 at 8:02 AM, revealed CNA D performed and CNA E assisted with incontinent/catheter care for Resident #77. CNA D washed her hands and applied gloves before she started incontinent care. CNA D cleaned Resident #77's crease between her right leg and groin area, then CNA D changed towels and proceed to clean her left leg and groin area. CNA D changed the towel and proceeded to clean the catheter tubing away from her but did not clean her meatus (a passage or opening leading to the interior of the body). CNA D did not clean Resident #77's mons pubis (the rounded mass of fatty tissue lying over the joint of the pubic bones). CNA D then provided perineal care to Resident #77's buttocks. CNA D was wearing the same gloves and removed a dirty incontinent pad and applied a clean incontinent pad. CNA D did not change her gloves and put the covers over Resident #77,then removed her gloves and washed her hands. During an interview on 6/26/24 at 8:32 AM, CNA E said she was 95% sure that CNA D missed a step while performing catheter care. CNA E said after washing the front peri area of the body CNA D was supposed to sanitize her hands then apply new gloves, then perform incontinent care to the backside of resident. CNA E said she would have cleaned the middle of the vagina and catheter first then clean the sides of the groin areas. CNA E said CNA D did not clean Resident #77's meatus. CNA E said the importance of catheter care was to keep the peri area clean and keep the catheter in place. CNA E said bad catheter care could cause infections. CNA E said when going from dirty to clean staff were supposed to change their gloves to prevent cross contamination. During an interview on 6/26/24 at 8:42 AM, CNA D said she felt like she did horrible with Resident #77's catheter care. CNA D said she felt like her clean hand got in the way. CNA D said she should have changed her gloves after peri care and catheter care. CNA D said the importance of catheter care was cleanliness and to keep the catheter intact. CNA D said bad catheter care could cause infections and not changing gloves during catheter care can cause cross contamination. During an interview on 6/26/24 at 10:23 AM, LVN F said CNAs should be going from the inside area to the outside areas with soap and water, unless the outer areas were soiled. LVN F said during catheter care cleaning they should be removing dirty gloves, sanitizing hands and changing gloves when they went from one part of the body to the other, to prevent cross contamination. LVN F said bad catheter care can cause a urinary tract infection with the elderly. During an interview and record on 6/26/24 at 11:11 AM, CNA G provided CNA D's skills check offs. CNA G said when she trained the CNAs she trained them on a dummy first. CNA G said CNAs should start catheter care with the top of the catheter and clean down. She said after she cleaned the tubing, removed dirty gloves, hands should be washed and clean gloves should be applied, then proceed to clean the peri area. She said after the peri area was cleaned, then clean across the top of the pubic area, then pat dry. She said after the front side was cleaned, then turn the resident over to proceed to clean the back area. She said to always have someone to help assist with catheter care . She said after she was done with catheter care she would roll her dirty pad, then change her gloves and sanitize my her hands, then apply clean gloves. She said she would have applied a clean incontinent pad under the resident, then the other person assisting with catheter care should remove the dirty pad. She said after the dirty pad was removed she would pull out the other side of the pad from underneath the resident. CNA G said improper catheter care could cause an UTI (urinary tract infection) or other infections. Record review of CNA D's skills check off dated 2/28/24 revealed CNA D passed and was very nervous, but she would be rechecked on her skills later. CNA D skills recheck off dated 4/1/24 revealed CNA D did very good, but she second guessed herself. During an interview on 6/26/24 at 2:12 PM, LVN F said before applying a catheter or replacing a catheter there should always be a physician or a nurse practitioner order reviewed. LVN F said the orders were typically on the MAR. LVN F said the charge nurses put in phone orders and the nurse that did the resident's admission usually put in their orders. LVN F said the way the nurses knew when orders were due was the orders came up on the MAR to inform them. LVN F said she typically read the orders of the resident and verified the orders before she changed a catheter. During an interview on 6/26/24 at 2:19 PM, the ADON said there should be orders for a catheter and catheter care on the resident's chart. The ADON said the orders should list the size and the amount of fluid should be placed in the bulb and the frequency the catheter should be changed. The ADON said the admitting nurses should put in the resident's orders, but any nurse can put in orders. The DON and ADON check the orders after the nurses. The ADON said he except the CNA to perform catheter care and go from clean to dirty. He said the CNAs should be washing their hands and changing their gloves in between steps. The ADON said the risk of not performing hand hygiene during catheter care could result in an infection. During an interview on 6/26/24 at 2:29 PM, the DON said there should be an order for an indwelling catheter. She said the order should had the size of the catheter, the amount of fluid in the bulb and when to change the catheter. The DON said the treatment nurse or the admitting nurse usually put the resident's orders in. The DON said the order fell through, because Resident #77's orders were discontinued when she was discharged to the hospital and the admitting nurse forgot to put the orders back in. The DON said during catheter care the CNAs were supposed to go from clean to dirty and change their gloves periodically. The DON said proper catheter care prevented infections. During an interview on 6/26/24 at 2:37 PM, the ADM said there should be an order for an indwelling catheter. The ADM said when applying a catheter, the nurse should be following the doctors' orders. The ADM said she expected the CNAs to use the correct PPE and follow the standard precautions guidelines, with incontinent care and catheter care. The ADM said staff members should be trying to prevent cross contamination and infections throughout the facility. Review of a Catheter Care, Urinary Policy dated revised August 2022 revealed .the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Follow aseptic technique when inserting a urinary catheter. Use aseptic technique when handling or manipulating the drainage system. Routine perineal hygiene: With non-dominant hand separate the labia of the female resident. Maintain the position of this hand throughout the procedure. Assess the urethral meatus. For a female resident: Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse the labia. Use one area of the washcloth (or wipe) for each downward, cleansing stroke. Change the position of the washcloth (or wipe) and cleanse around the urethral meatus. Do not allow the washcloth/wipe to drag on the resident's skin or linen. With a clean washcloth (or wipe), rinse using the above technique. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hand thoroughly. Reposition the bed covers. Make the resident comfortable. Review of Physician Services Policy dated revised February 2021 revealed .The medical care of each resident is supervised by a licensed physician. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 2 of 7 residents (Resident #58 and Resident #73) reviewed for unnecessary medications. The facility failed to ensure Resident #58 and Resident #73 had a stop date or duration for PRN Lorazepam (a medication used to treat anxiety). These failures could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #58's face sheet, dated 06/26/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Acute on chronic combined systolic and diastolic heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), cardiomyopathy (an acquired or hereditary disease of heart muscle), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Parkinson's disease (a disorder of the central nervous system that affects movement). Record review of Resident #58's quarterly MDS assessment, dated 05/09/24, indicated she was usually able to make herself understood and she usually understood others. She had a BIMS score of 7, which indicated severe cognitive impairment. The assessment further indicated Resident #58 did not receive any antipsychotics during her 7-day assessment window. Record review of Resident #58's Physician's orders, printed on 06/26/24, indicated the following orders: *Lorazepam intensol 0.5mg by mouth every four hours as needed for anxiety. The start date was 02/09/24. There was no stop date. There was no duration given for the order. *Lorazepam 1ml by mouth every four hours as needed for anxiety. The start date was 02/09/24. There was no stop date. There was no duration given for the order. Record review of Resident #58's MAR for the month of February 2024 indicated she did not receive the PRN Lorazepam from 02/09/24 through 02/29/24. Record review of Resident #58's MAR for the month of March 2024 indicated she did not receive the PRN Lorazepam during the month of March. Record review of Resident #58's MAR for the month of April 2024 indicated she did not receive the PRN Lorazepam during the month of April. Record review of Resident #58's MAR for the month of May 2024 indicated she did not receive the PRN Lorazepam during the month of May. Record review of Resident #58's MAR for the month of June 2024 indicated she did not receive the PRN Lorazepam during the month of June as of 06/26/24. Record review of Resident #58's consultant pharmacist physician communication, dated 03/11/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: She's on hospice. There was no indicated duration or stop date for the PRN lorazepam. Record review of Resident #58's consultant pharmacist physician communication, dated 04/04/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: She is on hospice. Extend Rx. There was no indicated duration or stop date for the PRN lorazepam. Record review of Resident #58's consultant pharmacist physician communication, dated 05/05/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: Hospice [patient]. There was no indicated duration or stop date for the PRN lorazepam. Record review of Resident #58's consultant pharmacist physician communication, dated 06/04/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: [patient] on hospice. There was no indicated duration or stop date for the PRN lorazepam. During an interview on 06/26/24 at 10:10 AM, RN A said she was taking care of Resident #58 on that day. She said Resident #58 had 2 orders for PRN Lorazepam and neither have a stop date. She said the orders should have a stop date at 14 days so the provider could re-evaluate the medications. She said there was a potential for the resident to receive too much medication if it was not stopped after 14 days. 2. Record review of Resident #73's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #73 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, memory, related to disease of the brain), Alzheimer's (progressive disease that destroys memory and other important mental functions), and anxiety disorder. Record review of Resident #73's significant change MDS dated [DATE] revealed she had a BIMS of 99, which indicated she had severe cognitive impairment and was unable to complete the interview. The MDS did not indicate Resident #73 had an anxiety disorder. The MDS indicated Resident #73 received an antianxiety medication (used to treat anxiety). Record review of Resident #73's care plan dated 6/24/24 revealed she had a potential for drug toxicity due to psychotropic medication regimen. Resident #73 took lorazepam, and the facility was to monitor her for side effects of lorazepam. Record review of Resident #73's Physician Orders dated June 2024 revealed an order for lorazepam 0.5 mg by mouth every four hours as needed for anxiety/agitation with a start date of 05/03/24. There was no end date. There was no documentation in the order for the duration of the order. Record review of Resident #73's care plan dated 6/24/24 revealed she had a potential for drug toxicity due to psychotropic medication regimen. Resident #73 took lorazepam, and the facility was to monitor her for side effects of lorazepam. Record review of Resident #73's MAR dated May 2024 revealed she had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety/agitation with a start date of 5/03/24. There was no stop date. There was documentation of Resident #73 only receiving PRN lorazepam 0.5 mg once on 5/03/24 and twice on 5/04/24 . Record review of Resident #73's MAR dated June 2024 revealed she had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety/agitation with a start date of 5/03/24. There was no stop date. There was no documentation of Resident #73 receiving PRN lorazepam 0.5 mg during the month of June. Record review of the facility's Consultant Pharmacist/Physician Communication note dated 6/03/24 for Resident #73 revealed the consulting pharmacist had sent a note to the physician indicating . the resident was receiving the following psychotropic medication on a PRN basis: lorazepam 0.5 mg every four hours PRN . Per regulatory guidelines, the duration of treatment with such medications or a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believed it was appropriate . Please evaluate the continued need for this medication . If it was to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration . The physician's response was to continue the medication due to the resident was on hospice and there was no specific duration documented for the medication. During an interview on 06/26/24 at 11:38 AM, the ADON said there should be a 14 day stop date on PRN psychotropics. He said personally he thought hospice was an appropriate rationale for continuing the lorazepam. He said the ADON was responsible for ensuring that PRN psychotropics had an end date. He said the medication not having a stop date could become an unnecessary medication. The nurses should also ensure that psychotropics that are PRN have an end date. During an interview on 06/26/24 at 11:43 AM, the DON said she felt that the rationale of being on hospice was an appropriate rationale for continuing the PRN lorazepam orders indefinitely. She said the regulation said that all psychotropics that were PRN should have a 14 day stop date. She said she did not think there was a negative effect to the resident for not having a stop date. She said the bedside nurse was responsible for ensuring that all prn psychotropics had stop dates. She said the ADON, DON, and medical records personnel were also responsible for ensuring that PRN psychotropics have a stop date. During an interview on 06/26/24 at 11:55AM, the Administrator said she was unsure if there should have been a stop date for PRN psychotropics. She said she was unsure of any negative effect to the residents as a result of the medication continuing to be on the orders. She said she was not a medical provider, so she did not know. She said nursing and pharmacy were responsible for ensuring that the PRN psychotropics have a stop date. Record review of the facility's policy, Psychotropic Medication Use, dated July 2022, stated: .A psychotropic medication is any [medication] that affects brain activity associated with mental processes and behavior . .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnoses specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 22 residents (Resident #14, Resident 73, Resident #53, and Resident #186) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document Resident #53's chair alarm use. 2.The facility failed to accurately reflect Resident #14 was PASRR positive (identified as having a serious mental illness) on her annual MDS assessment. 3. The facility failed to accurately reflect Resident #73 was receiving hospice services on her significant change MDS assessment. 4. The facility failed to accurately reflect Resident #186 had bed and chair alarms on his quarterly MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of an undated face sheet revealed Resident #53 was an 86- year-old-female admitted to the facility on [DATE] with the diagnoses of Respiratory Failure with Hypoxia (happens when you don't have enough oxygen in your blood), Encephalopathy (a group of conditions that cause brain dysfunction), Acute Kidney Failure (Acute kidney failure occurs when your kidneys suddenly become unable) Record review of an Annual MDS dated [DATE] for Resident #53 revealed a BIMS of 05, which indicated severe cognitive impairment. The MDS also revealed Resident #53 was not marked for use of a chair alarm. Record review of resident #53's care plan revealed a problem initiated on 9/8/2023, I am at risk of falls and history of falls with multiple fractures and poor safety awareness. Fall alarm to wheelchair and bed. Record review of Resident #53's consolidated physician's orders dated 4/16/23 revealed Resident #53 had an order for, Alarm pad to chair and bed until further notice - make sure this is in place. During an observation on 06/24/24 at 10:40 a.m., Resident # 53 was observed with a chair alarm on her wheelchair. A chair alarm device that had a wire with a clip was attached to Resident #53's clothing. During an interview and observation on 06/25/24 at 08:49 a.m., revealed Resident #53 had a chair alarm attached to her clothing. Resident #53 said she did not know what it was. Resident #53 said it did not bother her. Resident #53 said she was not scared of the noise that was made by the wheelchair alarm. During an interview on 6/26/24 at 11:40 a.m., the DON said she expected accurate and timely MDSs as per facility policy. She said incorrect MDSs could affect the information transmitted to the state. She said it was the MDS nurse's responsibility to correctly code the MDS for residents. During an interview on 6/26/24 at 11:52 a.m. the ADM said it was the MDS nurse who was responsible for correctly coding the MDS. She said she expected accurate and timely MDSs. She said incorrect MDSs affected the information transmitted to State. 2. Record review of Resident #14's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses of Primary Lateral Sclerosis (rare, slowly progressive neuromuscular (nerve and muscle) disease that leads to lose of muscle control and movement problems) and schizoaffective disorder, bipolar type (mental illness that combines symptoms of schizophrenia, such as hallucinations (seeing, hearing, smelling, tasting something that is not there), delusions (belief or altered reality that was persistently held despite evidence or agreement to the contrary), and psychosis (mental disorder characterized by a disconnection from reality), with a mood disorder such as mania (excessive enthusiasm or desire, or obsession) and depression (persistent sadness)). Record review of Resident #14's annual MDS assessment dated [DATE] indicated she marked as not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS did not indicate Resident #14 had serious mental illness. The MDS indicated a BIMS score of 12 which indicated Resident #14 had moderate cognitive impairment. The MDS indicated Resident #14 had a diagnosis of Schizophrenia (for example schizoaffective and schizophreniform disorders). Record review of Resident #14's PASRR Comprehensive Service Form dated 4/10/24 indicated Resident #14 was PASRR positive for mental illness only. Record review of Resident #14's care plan printed 6/26/24 revealed she was PASRR positive for mental illness with a diagnosis of Schizoaffective disorder Bipolar Type. Resident #14 refused PASRR services but was receiving counseling services. 3. Record review of Resident #73's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #73 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, memory, related to disease of the brain), Alzheimer's (progressive disease that destroys memory and other important mental functions), and anxiety disorder. Record review of Resident #73's significant change MDS dated [DATE] revealed she had a BIMS of 99, which indicated she had severe cognitive impairment and was unable to complete the interview. The MDS did not indicate she was receiving hospice services. Record review of Resident #73's Physician Orders dated June 2024 revealed an order to admit to hospice for diagnosis of dementia with a start date of 5/03/24. Record review of Resident #73's care plan printed 6/24/24 revealed she was receiving hospice care. 4. Record review of Resident #186's face sheet dated 6/25/24 revealed he was [AGE] years old and admitted to the facility initially on 8/09/19 and re-admitted on [DATE]. Resident #186 had diagnoses of dementia, Parkinson's (disease of the brain that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and delusional disorder (belief or altered reality that was persistently held despite evidence or agreement to the contrary). Record review of Resident #186's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 7, which indicated he had severe cognitive impairment. The MDS did not indicate he had bed or chair alarms. Record review of Resident #186's Physician Orders dated June 2024 revealed there was no orders for bed or chair alarms. Record review of Resident #186's care plan dated 6/26/24 revealed he was at risk for falls with history of multiple falls and had an intervention to place alarms as appropriate. During an interview and observation on 6/24/24 at 11:00 AM, Resident #186 was self-propelling himself in his wheelchair in the hallway with a chair alarm attached to the back of his wheelchair that attached to a pad under him. Resident #186 said he was doing just fine, and he did not know what the chair alarm was for. During an observation on 6/25/24 at 3:52 PM, Resident #186 was lying in bed asleep with a bed alarm attached to a pad under Resident #186. During an interview on 6/26/24 beginning at 2:24 PM with both MDS Coordinators, MDS B said she was responsible for the MDS assessments of residents with Medicare and MDS C said she was responsible for the MDS assessments of residents with Medicaid and private pay. MDS C said she completed Resident #73's significant change MDS assessment due to Resident #73 was admitted to hospice services. MDS C said she was responsible for ensuring the MDS assessments were accurate. MDS C said the MDS assessment calculated the RUG (Resource Utilization Group) score, and it reflected what the resident's care needs were. MDS C said if the MDS assessment was not accurate then the resident's care plan may not be accurate due to the care areas marked on the MDS assessment helped build the care plan for the resident. MDS C said hospice should have been checked on the Resident #73's significant change MDS assessment. MDS C reviewed Resident #73's 5/03/24 significant change assessment and said hospice was not checked. MDS C said she was responsible for Resident #186's MDS assessments. MDS C said Resident #186 had bed and chair alarms in place for a long time because he was a fall risk. MDS B reviewed Resident #186's MDS assessment and said Resident #186 did not have bed or chair alarms checked on his MDS assessment. MDS B said bed and chair alarms should have been included on Resident #186's MDS assessment. MDS C said she was responsible for Resident #14's MDS assessments. MDS C and MDS B said Resident #14 was PASRR positive and it should have been marked on her annual MDS assessment. MDS B reviewed Resident #14's annual MDS assessment and said PASRR was not marked on her MDS assessment. MDS B and MDS C said the PASRR section usually prepopulated, and they did not know why it did not prepopulate on Resident #14's MDS assessment, but it should have been marked. During an interview on 6/26/24 at 2:45 PM, the ADM said the MDS nurses were responsible for ensuring the MDS assessments were accurate. She said the MDS assessment should paint an accurate picture to the state on what level of care they were providing to the residents. The ADM said she would expect the MDS assessments to be accurate and paint a picture of the resident. Requested a policy on Accuracy of Assessments on 6/26/24 at 1:30 PM from the ADM and was provided policies on Electronic Transmission of MDS, MDS Completion and Submission Timeframes, and MDS Error Correction. These policies did not address accuracy of assessments. Record review of the Resident Assessment Instrument 3.0 User's Manual (RAI) last revised October 2023, revealed . the RAI process was the basis for the accurate assessment of each resident . Code yes if PASRR Level II screening determined that the resident had a serious mental illness . code serious mental illness, if resident had been diagnosed with a serious mental illness . code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions . identify all alarms that were used at any time during the 7-day look back period . bed alarm . chair alarm . code 2 if used daily .

Based on observation, interviews 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 reviewed for kitchen sanitation in that: The facility did not label, or date food stored in the kitchen's refrigerator. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on 06/24/24 at 8:55 a.m., it was observed that a whole pie, a slice of pie, French fries, tater tots, 1 gallon of partially eaten ice cream, and 2 bags of hard-boiled eggs did not have a date or label. During an interview on 6/26/24 at 8:53 a.m., the Dietary Manager said he expected that his staff to follow the dietary policy by dating and labeling all foods stored in their kitchen. He stated that residents can be placed at risk of foodborne illness by eating contaminated food. During an interview on 6/26/24 at 11:40 a.m., the DON said she expects that all facility staff including the kitchen staff follow facility policy. She said that residents could be placed at risk of foodborne illness if they ate expired food. During an interview on 6/26/24 at 11:52 a.m., with the ADM she said she expected that all facility policies are followed. She said she expected that food is labeled, dated and stored properly. She said that residents could be placed at risk of foodborne illness if they ate contaminated food. Review of the facility document revised on 12/4/2006, titled Storage of Frozen and Refrigerated foods provided by the Administrator revealed: Refrigerate foods in shallow containers to speed the cooling process. Label to date placed in the refrigerator, time, expiration or use by date. Once a product has been opened the date opened shall be written on the product and use by date is 7 days from date opened. Food prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 7 days from the date Prepared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 4 residents reviewed for accidents. (Residents #3) The facility failed to ensure Resident #3 had on a Wanderguard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time) leading him to be able to elope out of the door at the end of the 400 Hall. This failure could place residents at risk of injury from accident and hazards. Findings included: 1. Record review of the face sheet dated 06/12/24 revealed Resident #3 was [AGE] years old and admitted on [DATE] with diagnoses including stroke, dementia, and anxiety disorder. The face sheet revealed Resident #3 was discharged on 05/07/24. Record review of the quarterly MDS dated [DATE] revealed Resident #3 was discharged to the hospital on [DATE]. The MDS revealed Resident #3 had a BIMS score of 00 which indicated severe cognitive impairment. The MDS indicated Resident #3 was independent with ADLs. The MDS revealed the resident required substantial/maximal assistance with chair/bed-to-chair transfers and the resident used a wheelchair. Record review of the care plan last revised on 04/22/24 did not indicated Resident #3 was an elopement risk or required a Wanderguard. Record review of an Elopement Risk Alert dated 09/30/20 indicated Resident #3 had dementia with behaviors. The areas/places to focus search indicated, .will try to get home .angry with family for moving him to SNF . Record review of an Elopement Risk assessment dated [DATE] indicated Resident #3 had an elopement risk score of 10. The assessment indicated a resident with a score of 10 or greater was an elopement risk. Record review of an Elopement Risk assessment dated [DATE] indicated Resident #3 had an elopement risk score of 12. The assessment indicated a resident with a score of 10 or greater was an elopement risk. No other Elopement Risk Assessments for Resident #3 were provided by the facility prior to exit. Record review of a Wanderguard, Personal Alarms, and Door Alarm Log for 05/2023 and 06/2023 indicated there was no documentation of Resident #3's Wander Guard being checked on 05/10/23, 05/12/23, 05/15/23, 05/17/23, 05/19/23, 05/22/23, 05/24/23, 05/26/23, 05/29/23, 05/31/23, 06/02/23, 06/05/23, 06/07/23, 06/09/23, 06/12/23, 06/14/23, 06/16/23, 06/19/23, 06/24/23, 06/23/23, 06/26/23, and 06/28/23. Record review of a Provider Investigation Report dated 06/30/23 indicated Resident #3 eloped from the facility on 06/29/23 at 10:30 p.m. The report indicated Resident #3 had dementia with behaviors and exit-seeking was a new behavior. The report indicated Resident #3 exited a hallway door at 10:30 PM without staff noticing. He was outside until 10:45 when staff heard him at the front door . A Wander Guard alert tag was immediately placed on the resident so that hallway exits will delay egress and sound an alarm if the resident seeks exit. The Investigation Summary indicated, Surveillance video was reviewed. The resident experienced no injury or adverse events. He let himself out of the building . Record review on an Intake Investigation Worksheet with a received date of 06/30/23 concerning Resident #3 indicated, .The resident had no injuries upon assessment .the resident eloped through the laundry room exit at 10:38 PM, and staff did not discover it until he was heard at the front door at 10:53 PM .The resident has not tried to elope in a few years and did not have a Wander Guard device on at the time . The intake was a facility reported incident reported by the Administrator. During an interview on 6/12/24 at 1:03 p.m., LVN E said on the evening of 06/29/23 they had put Resident #3 to bed, but he had gotten back up. She said he always wandered. She said she was charting. She said she looked up and he was gone. She said an alarm never went off. She said she could not remember but he may not have had a wander guard on. She said she did not know why he did not have one on. She said staff began looking for him because they did not see him. She said they found him outside the exit door at the end of the 500 Hall. She said he was still in his wheelchair. She said he had no injuries. She said, He was perfectly fine. She said no staff witnessed him outside. She said, as far she knew, he never left the property. She said he was not sweaty or hurting. She said after that, they increased supervision for Resident #3. She said someone told her he had been to the hospital and his Wanderguard had been cut off . She said she knew he would refuse to have his Wanderguard checked at times. During an interview on 6/12/24 at 2:05 p.m., the DON said she was notified by staff that Resident #3 had eloped when staff discovered he was missing. She said the Administrator had completed the investigation. She said there were cameras outside, and he never left the property. She said he had no injuries. She said he had a Wanderguard after he was admitted . She said the nurse said he had been to the hospital and the hospital cut it off. She said the nurse said the Wanderguard had not been replaced before he eloped. She said there was no documentation during the month of June 2023 that he had been out to the hospital, and he did have his Wanderguard on. During an interview on 06/12/24 at 2:54 p.m., CNA E said on the evening of 06/29/23, Resident #3 could not sleep and wanted to get up. She said he was moving around at the nurse's station. She said he was in a good mood. She said it had not been less than 5 minutes and suddenly she did not see him. She said she did not hear an alarm. She said they began looking down each hall for him. She said it did not take long at all. She said they could hear him making sounds outside. She said they followed his voice. She said he had gone out the door on the 400 Hall. She said he never left the property. She said he had no injuries. She said he was not hot. She said he was found very quickly. She said he was not upset and did not realize what was going on. She said she did not know anything about the Wanderguard. During an interview on 6/13/24 at 11:36 p.m., the Maintenance Supervisor said if a resident had a Wanderguard on, the door at the end of the 400 Hall would still open but would alarm. He said he was unaware of any doors malfunctioning over the last year. He the nursing staff checked to make sure the Wanderguards were working. He said it had never been reported to him that a Wanderguard was malfunctioning. He said to his knowledge the door had no issues in the last year. During an interview on 6/13/24 at 12:16 p.m., CNA F said on the evening of 06/29/23, Resident #3 was talking to her. She said she went to make her rounds and when she came back he was gone. She said the door never alarmed. She said she started looking for him. She said she started her rounds at ten. She said it was at least 30 minutes before she realized he was missing. She said he was found out beside the building near the 500 Hall. She said he looked fine. She said there was nothing wrong with him. She said he was in no distress. She said he never left the property. She said she was amazed he got as far as he did. She said he normally stayed around the nurse's station. During an interview on 6/13/24 at 12:38 p.m., Restorative Aide G said it was her responsibility to make sure all Wanderguards were working. She said she was told that Resident #3 did not have on a Wanderguard on 06/29/23. She said it had been a long time and she could not remember. She said she did not know why he would not have had on his Wanderguard. She said she checked all residents with Wanderguards on Mondays, Wednesdays, and Fridays. She said she wheeled each resident to each door to make sure they were working. She said a Wanderguard did not cause the door on the end of the 400 Hall to lock, but it would alarm if someone with a Wanderguard went out. During an interview on 06/13/24 at 1:26 p.m., the DON said only the front door and the dining hall door locked with Wanderguards and all doors alarm after hours when anyone goes out . She said she thought the time began at 6 p.m. She said only the glass door going to the laundry room did not alarm during the day. She said she did not know why Resident #3 did not have his Wanderguard on. She said she would assume he had been out to the hospital, and it would have been cut off. She said she had found no hospital records for the month of June 2023 that would indicate he had been out. She said right after the incident, staff told her they did not know if he had it on. She said she did have staff verify he had it on, but she did not know the date. She said the only elopement risk assessments was the one from October 2020 and the one done March 2024. She said a resident that eloped, obviously they could die, heat exposure, cold exposure, and vehicles. She said there had been no other elopements since 6/29/2023. During an interview on 06/13/24 at 2:17 p.m., the Administrator said Resident #3 went out the door at the end of the 400 Hall on the night shift. She said he went out in his wheelchair and no alarms sounded. She said she watched him leave on a video and she was able see he went around the side of the building. She said he never left the property. She said staff told her he did not have a Wanderguard on when he went out. She said a resident that eloped could have been injured or gotten lost. During an observation on 6/13/24 at 2:20 p.m., the CNA Supervisor, in presence of the DON, wheeled a resident with a wander guard in a wheelchair just out the 400 Hall outside door and the alarm sounded and they had to put a code in to silence the alarm. Review of a Wandering and Elopements facility policy last revised in March 2019 indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . if identified at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure LVN A followed the facility's Administering Medications policy which resulted in Resident #1 receiving Resident #2's hydrocodone/APAP 7.5 mg/325 mg tablet (opioid analgesic medication used to treat pain) that was not prescribed to her. This failure could place residents at risk of receiving incorrect medications, dosages of medications , and significant adverse effects from medication errors. Findings included: 1. Record review of Resident #1's face sheet dated [DATE] revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia (forgetfulness that interferes with daily functioning), cognitive communication deficit, muscle weakness, repeated falls, and chronic pain. Record review of Resident #1's annual MDS assessment dated [DATE] revealed she was usually understood and usually understood others. Resident #1 had a BIMS score of 5, which indicated she had severe cognitive impairment. Resident #1 was independent with most ADLs. Resident #1 received as needed pain medications for frequent pain that rarely affected her day-to-day activities. Record review of Resident #1's care plan with a start date of [DATE] revealed she rarely had pain and had interventions including to administer medications as ordered and monitor her for side effects and effectiveness of her medications and contact her physician as needed. Resident #1 was at risk for falls. Record review of Resident #1's Physician Orders dated [DATE] revealed an order for Tramadol 50 mg (opioid analgesic medication used to treat pain) by mouth every four hours as needed for pain with a start date of [DATE]. Record review of Resident #1's Med Aide EMAR dated [DATE] revealed there was no documentation indicating Tramadol 50 mg by mouth had been administered [DATE]-[DATE]. Record review of Resident #1's Departmental Notes dated [DATE]-[DATE] revealed there was no documentation of Resident #1 complaining of pain or being administered a medication for pain on the 6 PM to 6 AM shift on [DATE]-[DATE]. Record review of Resident #1's Individual Patient's Antibiotic/Narcotic Record for Tramadol 50 mg tablets revealed the tablets expired on [DATE] and there was no documentation of medications given after that time. During an observation and interview on [DATE] at 2:30 PM, Resident #1 was clean and well groomed. She said she did not have any pain at the time. Attempted to notify Resident #1's RP on [DATE] at 3:02 and [DATE] at 12:44 PM, there was no answer, and a voicemail was left. Resident #1's RP did not return call prior to exiting the facility. 2. Record review of Resident #2's face sheet dated [DATE] revealed he was [AGE] years old and admitted to the facility initially on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses including fistula of stomach and duodenum (abnormal opening in the stomach or intestines that allows contents to leak into another part of the body), cognitive communication deficit, and chronic pain. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he was usually understood and understood others. Resident #2 had a BIMS of 11, which indicated he had moderate cognitive impairment. Resident #2 used a wheelchair for mobility and was dependent on staff assistance with most ADLs. Resident #2 received scheduled pain medications for occasional pain that occasionally affected his sleep and rarely affected his day-to-day activities. Record review of Resident #2's care plan with a start date of [DATE] revealed he had contractures to his right upper extremity and both lower extremities with interventions including pain medications as ordered and pain assessment per orders. Resident #2 was at risk of falls. Record review of Resident #2's Physician Orders dated [DATE] revealed an order for Hydrocodone 7.5/325 mg by mouth every six hours for pain with a start date of [DATE]. Record review of Resident #2's Med Aide EMAR dated [DATE] revealed he received hydrocodone/APAP 7.5 mg/325 mg by mouth every six hours (4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM) for pain with a start date of [DATE] and it was discontinued [DATE]. Record review of Resident #2's Individual Patient's Antibiotic/Narcotic Record for Hydrocodone 7.5 mg/325 mg revealed LVN A had administered 1 tablet to Resident #2 on [DATE] at 10:00 PM and 1 tablet on [DATE] at 5:00 AM. Resident #2's hydrocodone tablet count should have been 46, but there was a count of 45 circled by LVN A, indicating the count was wrong. During an observation and interview on [DATE] at 2:45 PM, Resident #2 was lying in bed and was clean and well groomed. He said he received routine pain medication, and his pain was managed. During an interview on [DATE] at 12:10 PM, LVN B said she was the oncoming nurse on [DATE] AM shift and counted narcotics with LVN A, who was the outgoing nurse from the night shift. LVN B said the count was wrong and it was her first day back on duty. LVN B said the count was wrong and she did not accept the cart keys, and she notified management the narcotic count was off by one hydrocodone for Resident #2. LVN B said she was instructed to start drug testing staff with access to that cart. LVN B said they tested LVN A and all staff that had been in that medication cart for the three days prior. LVN B said all staff were negative. LVN B said she did not know the outcome of the investigation. LVN B said the oncoming nurse counts the narcotic medications with the outgoing nurse each shift change, and then they sign the sheet together indicating the count was correct. LVN B said if the narcotic count was wrong, then the oncoming nurse should not accept the medication cart keys and then notify management. LVN B said if a resident voiced, they wanted something for pain, the nurse should have the resident rate their pain level. LVN B said she did not trust the computer and she always checked what the computer said the last medication dose was against what the narcotic log said the last dose was. LVN B said she would ask the resident their name if they were alert and oriented or use the picture in the chart to identify the resident. LVN B said staff should check the MAR, dose, route, and check the medication card for correct resident and correct medication/dose prior to administering a medication to a resident. LVN B said there should be name alert sticker (big orange sticker) on the medication cards to give staff a clue there were multiple residents with the same last name. During an observation and interview on [DATE] at 1:00 PM, MA C unlocked her cart for Hall 5 and the narcotic box, viewed Resident #2's medication card for hydrocodone, followed by Resident #2's medication card for Zolpidem, and then followed by Resident #1's medication card for Tramadol. There were no name alert stickers on the cards. MA C said the nurses count the narcotics when the nurses come in during the 6 AM or 6 PM shift changes. MA C said then she counts again with the nurse when she comes in at 8 AM before accepting the cart keys. MA C said she would count again with the nurse before going off duty. MA C said she ensured the correct medication was given to the correct resident by following the five rights of medication administration by verifying the right patient, medication, dose, frequency, and route. MA C said if a resident was given a medication that was not prescribed, it could lead to adverse reactions or side effects for the resident, or they could be allergic to the medication. During an interview on [DATE] at 1:56 PM, the DON said Resident #2's hydrocodone count was wrong at the end of the night shift. LVN A was coming off the night shift and she could not place where Resident #2's hydrocodone had gone, so it was reported. The DON said video surveillance showed LVN A took the hydrocodone to the wrong room to Resident #1. The DON said everything was signed out as if the hydrocodone was for Resident #2, however, LVN A took it to Resident #1 and administered the hydrocodone to Resident #1. The DON said they had name alerts with stickers for their paper charts and then a name alert was in the electronic chart also. The DON said they did not place name alert stickers on the medication cards. The DON said the risk of receiving a medication that was not ordered for the resident, could result in adverse drug reactions, allergies, and possible death. During an interview on [DATE] at 2:30 PM, the ADM said they watched LVN A on the video surveillance sign the medication out and walk it to Resident #1's room and not Resident #2, which left his hydrocodone count short one pill. The ADM said the effect of receiving a medication that was not prescribed to a resident would depend on the medication, but it could affect the resident and counter react with other medications. During an interview on [DATE] at 2:49 PM, LVN A said Resident #1 had requested something for pain. LVN A said she mistakenly pulled Resident #2's card of hydrocodone and administered one tablet to Resident #1. LVN A said she was honestly just not paying attention and pulled the wrong card. LVN A said both residents have the same last name. LVN A said she had never given Resident #1 anything for pain and did not even realize she had anything for pain. LVN A said she should pay more attention when administering medications. LVN A said she usually signed the medications out and she checked the orders to make sure the resident had something for pain. LVN A said she was aware of the five rights of medication administration, which included verifying the right resident, right medication, right dose, right time, and right route. LVN A said Resident #1 was administered a medication that was not prescribed to her, and the medication placed the resident at risk of having an allergic reaction to the medication, the medication could have been too strong, and it could have suppressed her breathing. LVN A said she did not realize she had done it until she and LVN B were doing the narcotic count at shift change and Resident #2's hydrocodone was short one tablet. LVN A said she called the DON to report the hydrocodone count was short for Resident #2. LVN A said she did a drug test and then continued to try to figure out what happened. LVN A said she realized later what she did, and she called the DON and then the DON and the ADM watched the video surveillance cameras and confirmed what happened. LVN A said she had taken a hydrocodone from Resident #2's medication card and administered it to Resident #1. LVN A said they continued to monitor Resident #1 for two days to monitor for any adverse reactions. LVN A said Resident #1 did not have any reactions to the hydrocodone. Record review of the facility's Medication Error Report dated [DATE] revealed Resident #1 was given Norco (hydrocodone) 7.5-325 mg from a resident's medication with the same last name across the hall, who did have an order for it. The report indicated Resident #1 did not have any adverse reactions from the Norco. The Assessment and Summary of the Error indicated the type of error was wrong resident and the reason for the error was failure to identify resident. Record review of the facility's policy titled Administering Medications, dated revised on [DATE] stated . medications were administered in a safe and timely manner, and as prescribed . medications were administered in accordance with the prescribers orders . the individual administering medications verifies the resident's identity before giving the resident his/her medications . methods of identifying the resident include . checking identification band . checking photograph attached to the medical record . and if necessary, verifying resident identification with other facility personnel . the individual administering medication checks the label THREE times to verify the right resident, right medication, right dosage, right time, and right method/route of administration before giving the medication . as required or indicated for a medication, the individual administering the medication records in the resident's medical record . the date and time the medication was administered, the dosage, route of administration . any complaints or symptoms for which the drug was administered . any results achieved and when those results were observed . and signature and title of person administering the drug . medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #17) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #17 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #17's face sheet, dated 04/25/2023, indicated Resident #17 was an [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included pain in left shoulder, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood). Record review of Resident #17's quarterly MDS assessment, dated 03/02/2023, indicated Resident #17 usually understood others and usually made himself understood. The assessment indicated Resident #17 was moderately cognitively impaired with a BIMS score of 10. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #17 was receiving Medicare Part A services starting on 02/13/2023 and the last covered day of Part A services was 03/14/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #17 of the option to continue services at the risk of out-of-pocket cost. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated she was responsible for ensuring Resident #17 was issued the form. The Administrator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The Administrator stated she was under the impression a SNF ABN form was only needed when a resident had a Part B cap or for services that the MD ordered that Medicare might not pay for. The Administrator stated there was no negative outcome for Resident #17 not receiving a SNF ABN form prior to covered days being exhausted. The Administrator stated the facility did not have a policy concerning notification of ending Part A Benefits or ABN/NOMNC letters. Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, indicated Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete annual comprehensive MDS assessment was transmitted to the CMS System within 14 days after completion for 1 of 22 residents (Resident #19) reviewed for MDS assessments. The facility did not ensure Resident #19's annual comprehensive MDS assessment was transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. The findings included: Record review of Resident #19's face sheet, dated 04/26/2023, revealed Resident #19 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #19's annual comprehensive MDS assessment, dated 03/21/2023, revealed the MDS assessment was completed on 04/05/2023 (V0200C2), which indicated the assessment was transmitted 5 days late. Record review of the MDS 3.0 NH Final Validation Report, completed on 04/24/2023, revealed on page 7 for Resident #19 Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessments (A0310A equals 01, 03, 04, or 05). During an interview on 04/26/2023 at 4:03 PM, the DON stated she was responsible for transmitting the MDS assessments. The DON stated Resident #19's assessment was transmitted late because there was a glitch in the system showing the transmission date for 04/25/2023. The DON stated once the MDS assessment was transmitted the date of transmission was updated to 04/19/2023, making the assessment late. The DON stated the facility staff went by the date in the system and did not calculate the transmission date themselves. The DON stated there was no system in place to monitor for late MDS transmissions because they rarely happened. The DON stated it was important to ensure MDS assessments were transmitted timely was because it was required. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated she expected MDS assessments to be transmitted on time. The Administrator stated it was important to ensure MDS assessments were transmitted timely to stay within regulation. Record review of the Electronic Transmission of the MDS policy, revised in September 2010, revealed 5. MDS electronic submission shall be conducted in accordance with current OBRA regulations governing the transmission of such data. Record review of the MDS Completion and Submission Timeframes policy, revised in July 2017, revealed 2. Timeframes for completion and submission of assessments is based on the current requirements published in the RAI manual. Review of the CMS RAI Version 3.0 Manual, dated October 2019, revealed in Chapter 5, page 5-3 Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 22 residents (Resident #2 and Resident #42) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #2's PASRR Evaluation on the MDS assessment. The facility failed to accurately reflect Resident #42's weight on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 04/25/2023, indicated Resident #2 was a 58-year- old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia, oropharyngeal (difficulty swallowing), personal history of traumatic brain injury (an injury to the brain that damages it and affects how it works), and hemiplegia, unspecified affecting right dominant side (weakness to right side of the body). Record review of the Comprehensive MDS assessment dated [DATE], indicated in Section A1500 Resident #2 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #2 understood others and sometimes was able to make self-understood. The MDS assessment indicated Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #2 required extensive assist with bed mobility, dressing, toilet use, and total dependence for eating personal hygiene and transfers. The MDS assessment indicated Resident #2 required partial/moderate assistance to roll left and right, move from sitting to lying, move from lying to sitting on the side of the bed, chair/bed-to-chair transfer, and toilet transfer. Record review of an undated care plan indicated Resident #2 required follow up on the PASRR Level 2 screening. Record review of Resident #2's PASRR Evaluation dated 03/02/2021 indicated he had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22. 2. Record review of a face sheet dated 04/25/2023 indicated Resident #42 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential primary hypertension (high blood pressure), and unspecified dementia, unspecified severity, without behaviors, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #42 understood others and was able to make self-understood. The MDS assessment indicated Resident #42 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #42 was dependent for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS assessment indicated Resident #42's weight was 110. Record review of the care plan with a problem onset date of 09/02/2020 indicated Resident #42 had a potential for weight loss to weigh and record per physician's orders. Record review of Resident #42's weights indicated her weight on 02/02/2023 was 144 lbs. During an interview on 04/26/2023 at 1:25 PM, the MDS Coordinator stated she was responsible for completing the MDS assessments, and the DON monitored her to ensure the MDS assessments were accurate. The MDS Coordinator stated the DON monitored the assessments for accuracy by reviewing 1-2 MDS assessments weekly. The MDS Coordinator stated Resident #42's weight was incorrect due to a typo. The MDS Coordinator stated she must have typed it in incorrectly and not realized it. The MDS Coordinator stated for Resident #2 she should have answered yes in Section A1500 indicating that Resident #2 was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS Coordinator stated when she completed Resident #2's MDS assessment it was her very first week and that section of the MDS was pre-filled and she had not changed the responses. The MDS Coordinator stated she was trained on completing MDS assessments by the previous MDS nurse, and that the DON notified her when MDS webinars were available, and they both watched them. The MDS Coordinator stated it was important to complete the MDS assessments accurately to show the best assessment of the resident at the time the assessment was completed. The MDS Coordinator stated completing the MDS assessments inaccurately did not affect the residents. During an interview on 04/26/2023 at 2:34 PM, the DON stated the MDS coordinator was responsible for the MDS assessments. The DON stated her expectations were that the MDS Coordinator was accurately completing them. The DON stated she signed the MDS assessments completed, but she did not have the time to review every MDS assessment. The DON stated she randomly performed audits on the MDS assessments to check them for accuracy, and if the MDS Coordinator had any questions regarding the MDS assessments they discussed how to complete them to ensure accuracy. The DON stated Resident #42's weight on the MDS assessment was incorrect and that it was a typo. The DON stated for Resident #2 there was a coding error that he should have been coded as being considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The DON stated it was important to complete the MDS assessments accurately to reflect the actual condition of the resident. The DON stated not completing the MDS assessments accurately affected the claim and payment of services, and they wanted the claim to be accurate. During an interview on 04/26/2023 at 5:15 PM, the Administrator stated the MDS Coordinator, and the DON were responsible for completing the MDS assessments. The Administrator stated she expected them to complete them accurately. The Administrator stated it was important to complete the MDS assessments accurately to correctly report to CMS the care the residents were receiving. The facility's policy on, Electronic Transmission of the MDS revised 09/2010 indicated the MDS coordinator was responsible for ensuring that appropriate edits are made prior to transmitting MDS data and staff members are trained on updates/revisions to the MDS form and software upgrades as they are released.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 22 residents reviewed for care plans. (Resident #2 and Resident #17) The facility failed to care plan that Resident #2 and Resident #17 were PASRR positive. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. The findings included: 1. Record review of a face sheet dated 04/25/2023, indicated Resident #2 was a 58-year- old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia, oropharyngeal (difficulty swallowing), personal history of traumatic brain injury (an injury to the brain that damages it and affects how it works), and hemiplegia, unspecified affecting right dominant side (weakness to right side of the body). Record review of the Comprehensive MDS assessment dated [DATE], indicated in Section A1500 Resident #2 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #2 understood others and sometimes was able to make self-understood. The MDS assessment indicated Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS assessment indicated Resident #2 required extensive assist with bed mobility, dressing, toilet use, and total dependence for eating personal hygiene and transfers. Record review of Resident #2's PASRR Evaluation dated 03/02/2021 indicated he had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22. Record review of an undated care plan indicated Resident #2 required follow up on the PASRR Level 2 screening. Resident #2's care plan did not indicate he had a developmental disability, which made him PASRR positive. 2. Record review of a face sheet dated 04/25/2023 indicated Resident #17 was an [AGE] year old female readmitted to the facility on [DATE] with diagnoses which included cerebral palsy (disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and schizoaffective disorder, bipolar type (a condition that can make you feel detached from reality and can affect our mood). Record review of Resident #17's Comprehensive MDS assessment dated [DATE] indicated in Section A1500 Resident #17 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment indicated Resident #17 understood others and was able to make self-understood. The MDS assessment indicated Resident #17 had a BIMS score of 8, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing and personal hygiene, and was dependent for toilet use and required supervision for eating. Record review of Resident #17's PASRR Evaluation dated 07/01/2022 indicated she had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22. Record review of Resident #17's care plan with a problem onset date of 06/15/2022 indicated Resident #17 required follow up on the PASRR Level 2 Screening. Resident #17's care plan did not indicate she had a developmental disability, which made her PASRR positive. During an interview on 04/26/2023 at 1:47 PM, the MDS Coordinator stated the Social Worker was responsible for care planning the residents PASRR status. The MDS Coordinator stated the ADON was responsible for overseeing the care plans. The MDS Coordinator stated if a resident was PASRR positive it should be part of the care plan, and it was important to include it so the staff could meet the resident's needs. During an interview on 04/26/2023 at 1:50 PM, the ADON stated the IDT was responsible for completing the care plans. The ADON stated she put the care plans in the electronic health record and the DON looked over them to ensure they included everything necessary for the resident's care. The ADON stated for Resident #2 and Resident # 17 she had put in the statement that they required follow up on the PASRR Level 2 Screening because this is what was put in for all the residents that were PASRR positive. The ADON stated she did not put in the care plan what qualified the resident to receive PASRR services or specific services recommended by PASRR. The ADON stated the care plans should be individualized and person centered. The ADON stated it was important for the care plans to be individualized and person centered so the staff would know how to take care of the residents. During an interview on 04/26/2023 at 2:00 PM, the Social Worker stated the IDT completed the care plans and the DON reviewed them. The Social Worker stated she had never been told the care plan should include that the residents were PASRR positive, and the services recommended by PASRR. The Social Worker stated the statement that the resident required follow up on the PASRR Level 2 Screening was used on all the residents that were PASRR positive. The Social Worker stated she did not know if using the same statement for all the residents was individualized and person centered. The Social Worker stated she did not know how not including the residents PASRR positive status and services recommended could affect the residents. During an interview on 04/26/2023 at 2:59 PM, the DON stated the IDT was responsible for completing the care plans, but she reviewed them to ensure they were complete. The DON stated the statement, in the care plan, the resident required follow up on the PASRR Level 2 Screening was used for all the PASRR positive residents. The DON stated they did not include in the care plan that the resident was PASRR positive, and they did not individualize the approach to indicate what qualified the resident for PASRR services or what recommendations for services were made. The DON stated it was important for the care plan to be individualized and person-centered for all the residents because it gave an outline of how to care for the resident. During an interview on 04/26/2023 at 5:19 PM, the Administrator stated the IDT team was responsible for ensuring the care plans were individualized and person-centered. The Administrator stated the DON reviewed the care plans. The Administrator stated she expected the care plans to be person centered and individualized. The Administrator stated the residents PASRR positive status, and any recommendations made by PASRR should be included in the care plan. The Administrator stated the resident not having a person centered and individualized care plan would not be about the care they need. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and implemented for each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident # 56) reviewed for dialysis. 1.The facility failed to have a physician's order for dialysis for Resident #56. 2.The facility failed to ensure nursing staff monitored Resident #56's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection. 3. The facility failed to develop a person-centered care plan for Resident #56's dialysis treatments and care. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings include: Record review of Resident #56's face sheet dated 04/25/23, indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #56 had a diagnoses of type 2 diabetes (blood sugar disorder), cerebral infarction (lack of adequate blood supply to the brain cells) and stage 5 end stage renal disease (kidney failure). Record review of Resident #56's MDS dated [DATE], indicated he had a BIMS score of 15 suggesting cognitively intact. The MDS indicated Resident #56 had the ability to understand others and made himself understood. The MDS indicated Resident #56 had a diagnoses of End stage renal disease and dependence on renal dialysis. Record review of Resident #56's care plan last updated on 04/06/2023 did not reveal Resident #56 was receiving dialysis, the venous catheter was being monitored by the nurses for signs and symptoms of infection, or auscultation/palpation of the AV fistula (pulse, bruit and thrill) was being done to assure adequate flood flow or monitoring of complications. Record review of the physician orders dated 04/2023 indicated Resident #56 had End stage renal disease. Resident #56's orders indicated to give midodrine 10mg by mouth every Monday, Wednesday and Friday before dialysis. Resident #56's physician orders indicated to monitor the left AC for signs and symptoms of infection daily and keep the site clean and dry. No order was indicated for dialysis. During an interview on 04/26/23 at 10:42 AM, Resident #56 stated he went to dialysis on Monday, Wednesday, and Friday. Resident #56 stated the nursing facility monitored his AC site and staff monitored for a bruit and thrill at the dialysis center and the nursing facility. During an interview on 04/25/23 at 4:25 PM, LVN B stated she did not know staff had to write an order for dialysis when residents were admitted to the facility. LVN B stated the process for dialysis residents upon admission to the facility was to receive report from the hospital and then the nurses would have added it to the 24-hour report. LVN B stated the facility only used one dialysis center and she checked Resident #56's dialysis site 3 times a week before sending him to dialysis. LVN B stated she had charted Resident #56 had a positive thrill and bruit when he was on skilled services in the nurse's notes, but she did not chart it anywhere now because he was no longer on skilled services. LVN B stated residents that received dialysis should be care planned, but either way she made sure Resident #56's site was looked at. LVN B stated not checking the bruit and thrill could have resulted in the resident being dialyzed and residents should have been checked for a bruit and thrill before they were sent to the dialysis center so they could have informed the dialysis center ahead of time to make other arrangements if needed. LVN B stated if Resident #56's AC site was not monitored, then the site could have clotted, or the resident could have been hospitalized due to an infection. LVN B stated the importance of having a dialysis order was so everyone was notified the resident was on dialysis. During an interview on 04/26/23 at 9:37 AM, the DON stated the charge nurses were responsible for adding an order for dialysis when residents were admitted to the facility. The DON stated a 2nd nurse double checked all the physician orders and then she was responsible for signing off on them. The DON stated, she did not go line by line when she checked the orders since a 2nd nurse had already checked them. The DON stated there was not a certain nurse that was designated to checking the physician orders as long as it was a 2nd nurse. The DON stated the IDT team was responsible for reviewing care plans quarterly and she was responsible for signing off on the care plans. The DON stated she expected the nurses to have checked Resident #56's AC site daily for infection and it should have been care planned because care plans address resident needs. The DON stated there was no harm in not care planning on a resident that received dialysis because the nurses were familiar with their residents, and it would have been indicated on the 24-hour report. During an interview on 04/26/23 at 5:30 PM, the Administrator stated she was not familiar on how the nurses documented on dialysis residents. The Administrator stated she expected the nurses to complete a person-centered care plan on dialysis residents and documentation to be done accurately. The facility's policy on, End-Stage Renal Disease, Care of a Resident with revised on 09/2010 indicated .agreements between this facility and the contracted ESRD facility included all aspects of how the residents care would be managed: how the care plan would be developed and implemented, and how information would be exchanged between the facilities. The residents comprehensive care plan would reflect the residents needs related to ESRD/dialysis care.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 2 of 4 meetings (May 2022, and September 2022) reviewed for QAPI. The facility did not ensure the ADON attended QAPI meetings in May 2022, and September 2022. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for May 2022 and September 2022 indicated the ADON did not sign in for their meetings. Record review of an undated form titled QAA Committee Information indicated the QAA Committee members were the Administrator, MD, Pharmacy Consultant, Social Worker, DON and the ADON. During an interview on 04/26/2023 at 8:45 a.m., the ADON stated she did not attend the meetings, but she did review the minutes with the DON. The ADON stated if she reviewed the minutes after the meetings, she should have signed the sign in sheet. The ADON stated I have no idea why I didn't sign the sign in sheet. The ADON stated she did not feel there was a negative outcome with her not attending the QAPI meetings due to her communicating with the DON. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated per documentation it appeared the ADON did not attend the quarterly QAPI meetings in May 2022, and September 2022. The Administrator stated if she attended the meetings or reviewed the minutes after the meetings, she should have signed the sign in sheet. The Administrator stated she did not feel there was a negative outcome with the ADON not attending the QAPI meetings Record review of the facility's undated Quality Assurance Performance Improvement Program Plan indicated the main purpose for the facility QAPI plan was to take a proactive approach to continually improve the way the facility care for and engage with residents, caregivers, and other partners so that the facility may realize their vision of becoming the community's first choice in skilled nursing care . the Administrator, DON, infection control, MD, consulting pharmacist, the ADON, and other staff as assigned will provide QAPI leadership by being on the QAPI Committee. The ADON will direct the QAPI Committee meetings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 1 of 1 facility and 1 of 1 staff (Laundry Aide O) reviewed for transportation of linens. The facility failed to ensure Laundry Aide O covered the clean linen cart while passing out resident's personal laundry. This failure could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life. The findings included: During an observation on 04/24/2023 between 9:48 PM - 10:08 PM, Laundry Aide O was passing out clean linen on Hall 2 ([NAME] St.) and Hall 5 (Church St.). The clean linen cart had a small purple blanket that was thrown on the top of the hanging clothes. The clothes were not fully covered and visible from the hallways. During an interview on 04/26/2023 at 2:53 PM, Laundry Aide O stated the clean linen carts should have been adequately covered while she was passing out resident's personal laundry. Laundry Aide O stated the small purple blanket was provided by the facility for use to cover the clean linen carts. Laundry Aide O stated she did not feel the purple blanket was large enough to adequately cover the clean clothes and had reported it to the Housekeeping Supervisor. Laundry Aide O stated it was important to ensure clean clothing was adequately covered during transportation to prevent cross-contamination and infection control. During an interview on 04/26/2023 at 3:36 PM, the Housekeeping Supervisor stated clean linen carts should have been covered during transportation and delivery. The Housekeeping supervisor stated the clean linens should not have been visible. The Housekeeping Supervisor stated she was unaware the purple blanket was too small. The Housekeeping Supervisor stated she monitored this by random checks and training during the hire and orientation process. The Housekeeping Supervisor stated it was important to ensure clean clothing was adequately covered during transportation and delivery to prevent cross contamination. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated clean linen carts should have been covered. The Administrator stated she expected laundry and housekeeping staff to ensure this was completed. The Administrator stated the Housekeeping Supervisor was responsible for ensuring the clean linen carts were adequately covered. The Administrator stated it was important because of infection control. Record review of the Departmental (Environmental Services) - Laundry and Linen policy, revised in January 2014, did not address delivery of clean linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4 of 12 resident rooms reviewed on Hall 5 (Room #'s 502, 204, 507, and 510) for resident rights and privacy. The facility failed to ensure Laundry Aide O, HA P, CNA Q and MA R knocked on Room #'s 502, 504, 507, and 510. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: Record review of an in-service, dated 04/21/2023, addressed knocking prior to entering a resident's room revealed Laundry Aide O, HA P, and MA R had signed the in-service. During an observation and interview on 04/24/2023 at 9:15 AM, MA R knocked on open doorframe and immediately entered room [ROOM NUMBER], interrupting conversation with state surveyor. MA R stood at medication cart in front of room [ROOM NUMBER]'s open door and proceeded to prepare the medication. Resident #50 stated he was used to the staff not knocking. During an observation and interview on 04/23/2023 at 9:21 AM, CNA Q entered room [ROOM NUMBER] without knocking, interrupting conversation with state surveyor. CNA Q walked over to the B bed, spoke with Resident #18, and then exited room. Resident #22 (A bed) stated the staff hardly knocked before coming in the room. Resident #22 stated it happened more often with the agency staff. During an observation and interview on 04/23/2023 at 9:34 AM, HA P knocked and immediately entered room [ROOM NUMBER], interrupting conversation with surveyor. Resident #63 immediately stopped talking while HA P took her water pitcher, filled it up, and brought it back. Resident #63 stated she was used to the staff just walking in. During an observation and interview on 04/23/2023 at 9:48 AM, Laundry Aide O opened and entered room [ROOM NUMBER] without knocking, interrupting conversation with surveyor. Resident #54 immediately stopped talking, while Laundry Aide O opened her closet door. Resident #54 stated staff walked in without knocking frequently. During a confidential telephone interview on 04/25/2023 at 9:23 AM, the family member stated respect and dignity for the residents was her only issue. The family member stated on numerous occasions the staff had left the door open while providing care. The family member also said staff hardly knocked when entering the residents' rooms. The family member stated it was sad to watch the facility staff provide no respect or dignity for the residents at the facility. During an interview on 04/26/2023 at 2:46 PM, a telephone interview was attempted with HA P to gather more information. HA P did not answer the phone and voice message was unable to have been left related to a full mailbox. During an interview on 04/26/2023 at 2:48 PM, a telephone interview was attempted with MA R to gather more information. MA R did not answer the phone and voice message was unable to have been left. During an interview on 04/26/2023 at 2:50 PM, CNA Q stated she remembered entering room [ROOM NUMBER] without knocking. CNA Q stated she should have knocked but the door was opened, and she did not realize the state surveyor was in the room. CNA Q stated it was important to knock and wait for a response to respect the resident and their privacy. During an interview on 04/26/2023 at 2:53 PM, Laundry Aide O stated she remembered entering room [ROOM NUMBER] without knocking. Laundry Aide O stated she should have knocked but another resident had asked for a shirt, and she was trying to find it. Laundry Aide O stated she was busier than normal and was in a hurry and did not remember to knock. Laundry Aide O stated it was important to knock and wait for a response to respect the resident and their privacy. During an interview on 04/26/2023 at 3:03 PM, CNA S stated facility staff should knock and wait for a response prior to entering a resident's room. CNA S stated it was important to knock to maintain the resident's dignity and privacy. During an interview on 04/26/203 at 4:03 PM, the DON stated she expected the facility staff to knock and wait for a response prior to entering a resident's room. The DON stated this was monitored by observations and education was provided to the staff member responsible. The DON stated it was important to knock to maintain resident's dignity and privacy. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated she expected facility staff to knock and wait for a response prior to entering a resident's room. The Administrator stated this was monitored by in-servicing staff and random checks. The Administrator stated it was important to knock prior to entering a resident's room out of respect for privacy and dignity. Record review of the Dignity policy, revised February 2021, revealed 7. Staff are expected to knock and request permission before entering residents' rooms.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings include: Record review of a nursing staff information sheet dated 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022 indicated that the facility did not have an RN in the facility. During an interview on 04/26/2023 at 9:15 a.m., the DON stated she was aware that there was a regulation to have 8 hours of RN coverage a day. The DON stated she was aware that there were days RNs were not scheduled due to no RN available. The DON stated she did have an ad running for a registered nurse. When asked how often days with no RN onsite, the DON stated currently about 4 days a month. The DON stated she was always available by phone if no RN was on schedule to work, and she lived 7 minutes from the facility. When asked how the facility provided care to residents that required a RN if one was not available to work, the DON stated she would come in to take care of the need. The DON stated she was unaware of a resident who needed care or services only performed by a RN and did not receive it. When asked possible negative outcomes to residents if no RN was on duty, she stated she did not think there would be one since she was on call and available and could be at the building quickly. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated the DON was responsible for ensuring a registered nurse was in the building 8 hours every day. When asked possible negative outcomes to residents if no RN was on duty, she stated she did not think there was one since the DON was always available by phone. The Administrator stated there was not a policy and procedure regarding RN staffing.

Based on interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 3 medication carts (nurse cart 5/6) reviewed for controlled medications. The facility did not ensure LVN's B, E, F, G, H, K, L, M, N counted controlled drugs every shift change. This deficient practice could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: During a record review and random count observation of nurse cart 5/6 with LVN B revealed missing signatures for Off duty and On duty for 4/9/2023, 4/10/2023, 4/11/2023, 4/14/2023, 4/18/2023, 4/19/2023, 4/20/23, 4/21/2023, 4/22/2023, 4/23/2023, 4/24/2023, and 4/25/2023 of the narcotic count sheet. Record review of a facility in-service dated 03/21/2023 titled Medication Destruction indicated LVN B, LVN E, RN F, and LVN G were in serviced on counting controlled drugs every shift change. During an interview on 4/26/2023 at 10:28 a.m., LVN E stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/9/2023. LVN E stated, I forgot to sign. LVN E stated this failure could potentially cause a drug diversion. An attempted telephone interview on 4/26/2023 at 10:34 a.m. with RN F, was unsuccessful. During a telephone interview on 4/26/2023 at 10:41 a.m., LVN H stated she should have signed the narcotic count log after counting the controlled drugs with the nurse after her shift on 4/9/2023. LVN H stated she forgot to sign. LVN H stated this failure could potentially cause a drug diversion. An attempted telephone interview on 4/26/2023 at 10:48 a.m. with LVN M, was unsuccessful. An attempted telephone interview on 4/26/2023 at 10:51 a.m. with LVN K, was unsuccessful. During a telephone interview on 4/26/2023 at 12:47 p.m., LVN N stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/22/2023 and 4/23/2023. LVN N stated, I forgot. LVN N stated this failure could potentially cause a drug diversion. During a telephone interview on 4/26/2023 at 1:00 p.m., LVN L stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/18/2023, 4/19/2023, and 4/18/2023. LVN L stated this failure could potentially cause a drug diversion. During a telephone interview on 4/26/2023 at 1:09 p.m., LVN B stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/10/2023, 4/11/2023, 4/14/2023, 4/19/2023, 4/20/2023, and 4/24/2023. LVN B stated, I don't know why it was overlooked. LVN B stated this failure could potentially cause a drug diversion. During an interview on 4/26/2023 at 10:53 a.m., LVN G stated she was responsible for counting and signing the narcotic count sheet with the on duty nurse at the end of her shift on 4/21/2023. LVN G stated, honestly I forgot. LVN G stated this failure could potentially cause a drug diversion. During an interview on 4/26/2023 at 9:15 a.m., the DON stated she expected nurses to signed at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated nurses were trained upon hire and as needed in serving. The DON stated her and the ADON were responsible for randomly checking the narcotic count sheets for accuracy in documentation. The DON stated the last audit was done on 4/7/2023 with the pharmacy consultant. The DON stated a couple of signatures were missing on the narcotic sheet for March and April. The DON stated nurses not ensuring narcotic count sheets were signed at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse could result in drug diversion. During an interview on 4/26/2023 at 4:49 p.m., the Administrator stated she expected narcotic sheets to be signed at the beginning and end of their shift after they completed count with the incoming and off-going nurse. The Administrator stated this failure could result in drug diversion. Record review of the undated facility's policy titled, Controlled Drug Policy and Procedure indicated, . 1. To provide physical facilities and method of operation for the administration and control of narcotics, which will meet the requirements of State and Federal narcotic enforcement agencies 2. To ensure maximum safety for patients and nursing personnel . Narcotic Count and Inventory . 1. Controlled drugs were counted every shift by the nurse and/or MA coming on duty with the nurse and/or MA going off duty .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents reviewed for unnecessary psychotropic medications. (Resident's #9 and #31) The facility failed to ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #9 and #31. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. The findings included: 1. Record review of Resident #9's face sheet, dated 04/26/2023, revealed Resident #9 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life events). Record review of the physician orders, dated April 2023, revealed Resident #9 had an order, which started on 11/22/2022, for clonazepam (anti-anxiety) 1mg by mouth three times daily. Record review of the MAR, dated April 2023, revealed Resident #9 received clonazepam 1 mg. Record review of the MDS assessment, dated 03/16/2023, revealed Resident #9 had clear speech and was understood by staff. The MDS revealed Resident #9 was able to understand others. The MDS revealed Resident #9 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed Resident #9 had a PHQ-9 score of 04, which indicated normal or minimal depression. The MDS revealed Resident #9 had no behaviors or rejection of care. The MDS revealed Resident #9 received an anti-anxiety and anti-depressant medication 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, dated 02/12/2023, revealed Resident #9 no longer exhibited physical combative behavior but did have verbally abuse behaviors. The interventions included: Administer behavior medication as ordered by physician. The care plan further revealed Resident #9 had potential for drug toxicity due to her medication regimen. Record review of the pharmacy recommendation, dated 01/09/2023, revealed Resident #9 was receiving clonazepam 1mg three times a day and it was due for review. The pharmacy recommendation further revealed a trial dosage reduction was recommended to decrease clonazepam to 0.5mg three times daily. No indication or rationale was provided for continued use. During an observation and interview on 04/24/2023 at 9:33 AM, Resident #9 was sitting up in her wheelchair. Resident #9 was wringing and constantly moving her hands. Resident #9 stated she was upset about some medications that were removed from her room. Resident #9 stated her medication regimen was sorta helping and she did not believe she was having side effects from the medications. 2. Record review of Resident #31's face sheet dated 04/26/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement and often includes tremors), adjustment disorder with mixed anxiety and depressed mood (feeling unmotivated, irritable and difficulty with concentrating) and chronic kidney disease (disease of the kidneys leading to renal failure). Record review of Resident #31's MDS dated [DATE] indicated a BIMS score of 8 indicating mildly impaired. The MDS indicated Resident #31 was understood and was able to understand others. The MDS indicated Resident #31 felt down or hopeless on 2-6 days and little interest in doing things on 7-11 days over the last 2 weeks. The MDS indicated Resident #31 had diagnoses of anxiety and depression. Record review of the care plan dated 01/21/2021 indicated Resident #31 had socially inappropriate and disruptive behavior that had been observed by staff causing the resident to fall. The goal was to maintain appropriate behavioral functioning by the next evaluation. The interventions included to encourage family to visit and to approach the resident in a warm and positive manner. The care plan indicated Resident #31 had a potential for drug toxicity due to clonazepam to control Parkinson's symptoms. The goal was for Resident #31 to be free of side effects from medications by next evaluation. The interventions included to monitor for side effects and effectiveness of the medication, contact the physician as needed, monitor the resident for tremors and document, observe the resident's gait for steadiness, balance, muscle coordination, and the ability to position and turn. Record review of the physician orders dated 04/2023 indicated Resident #31 was taking clonazepam 0.5mg by mouth twice daily due to Parkinson's. Record review of Resident #31's medication administration record indicated she was taking clonazepam 0.5mg by mouth twice daily for Parkinson's at 8:00 AM and 8:00 PM. Record review of the pharmacy recommendation form dated 03/05/2023 by the consultant pharmacist, indicated the psychoactive medication clonazepam 0.5mg twice a day was due for review, and to evaluate Resident #31 for a trial dosage reduction. The suggested change was to decrease clonazepam 0.5mg to daily. Physician A indicated to continue clonazepam 0.5mg twice daily. No indication or rationale was provided for continued use. During an interview on 04/26/23 at 8:59 AM, the ADON stated the GDRs were done monthly by the pharmacist. The ADON stated she was responsible for completing the GDR's and after she reviewed the report, it was then sent to clinic for the prescribing physician to sign. The ADON stated a staff nurse went to the clinic weekly to pick up documentation from the prescribing physicians. The ADON stated she, was not responsible for Physician A not providing a rational on the pharmacy recommendation form and she could not tell Physician A what to do. The ADON stated, if the resident was already on the medication and they were looking at reducing it, then she did not think there would be any consequences in not providing a rational, because the resident was being treated and not losing anything. The ADON stated, If they thought something needed to be changed, then they would notify Physician A and he would take care of it. During an interview on 04/26/23 at 9:37 AM, the DON stated the rationales should have been documented either on the pharmacy recommendation form or on a progress note. The DON stated Physician A knew his patients better than the staff and it could not harm the resident in any way that the rational was not provided. The DON stated staff would have pursued Physician A's recommendation if they thought it needed to be changed. During an interview on 04/26/23 at 1:36 PM, Physician A stated he usually indicates a rational on the pharmacy recommendation form and he usually does what the pharmacist recommends. Physician A stated he must have gotten in a hurry that day and just forgot to write a rational on Resident #31's form. Physician A stated if there was a concern with Resident #31, then the nurse would have added her comments on the form for him to look at or notified him verbally because the nurses were good at notifying him of any changes or recommendations that needed to be done. Physician A indicated the rational was used to communicate why changes in the medication were made. During an interview on 04/26/2023 at 3:54 AM, the ADON stated the system in place for pharmacy recommendations, which included GDRs was placing the pharmacy recommendation in the physician's folder and taking them to the physician's office once time weekly. The ADON stated each week, when a new folder was dropped off, the facility staff would ask if anything was ready to be picked up. The ADON stated the physician's had not been provided education on GDR recommendations and providing a clinical rationale for the continued use of a psychotropic medication. The ADON stated it was important to ensure clinical rationales were provided for continued use of psychotropic medications because it was regulatory. During an interview on 04/26/2023 at 4:03 PM, the DON stated education had not been provided to the physician's regarding documenting clinical rationales for continued use of psychotropic medications. The DON stated GDRs were important because it was regulatory. During an interview on 04/26/23 at 5:30 pm, the Administrator indicated the nurses were responsible for the pharmacy recommendation forms and she expected them to be done accurately. Record review of the facility's policy on, Tapering Medications and Gradual Drug Dose Reduction dated 7/2022 indicated . When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation and interview with the Dietary Manager of the refrigerator and freezer on 04/24/2023 starting at 9:52 a.m., revealed 2 plastic bags that was identified by the Dietary Manager as cheese pizza unlabeled and undated; 1 plastic bag that was identified by the Dietary Manager as corn dogs unlabeled; 1 plastic bag that was identified by the Dietary Manager as hamburger patties unlabeled; 2 bags that was identified by the Dietary Manager as tater tots unlabeled; 3 bags that that was identified by the Dietary Manager as French fries unlabeled; a tray with 10 (16oz) of margarine undated; 1 bag that was identified by the Dietary Manager as tomatoes unlabeled and undated; and 1 bag that was identified by the Dietary Manager as cucumbers unlabeled and undated. 2. During an observation on 04/24/2023 at 10:13 a.m., [NAME] C was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] C's hair was visible outside of the hairnet at the ears and necks. During an interview on 04/26/2023 at 12:25 p.m., Dietary Aide D stated the morning cook and aide were responsible for labeling and dating. Dietary Aide D stated that way staff would know what food and how old it was. Dietary Aide D stated these failures could potentially cause food borne illness/contamination. During an interview on 04/26/2023 at 12:34 p.m., [NAME] C stated whoever worked the morning that the truck comes in was responsible for labeling and dating. [NAME] C stated the hair restrained should cover her whole head. [NAME] C was unable to say why her hair was not covering her whole head. [NAME] C stated these failures could potentially cause food borne illness/contamination. During an interview on 04/26/2023 at 1:11 p.m., the Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager said all food should be labeled with date received and the date it was opened. The Dietary Manager stated when the food truck comes and delivers, whoever touched the item should label and date the item. The Dietary Manager stated when the food was opened it should be labeled and dated. The Dietary Manager stated all hair must be covered while in the kitchen area. The Dietary Manager stated she did daily spot checks during the day and address any issues. The Dietary Manager stated she was under the impression if you can see through the bag, it did not have to be labeled. The Dietary Manager stated these failures could potentially cause a food borne illness or cross contamination. Record review of the Food Receiving and Storage policy, last revised on 07/2014, indicated food shall be received and stored in a manner that complies with safe food handing practices . 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated . 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, functional, and comfortable environment for 1 of 14 residents (Resident #1), reviewed for a homelike environment. The facility failed to ensure Resident #1 had a bed remote control cord in safe operating condition. This failure could place residents at risk for injury and a diminished quality of life due to environment. The findings included: Record review of Resident #1's face sheet dated 3/03/2022 revealed an original facility admission date on 2/18/2019 and a re-admission date on 1/06/2021. Resident #1 was a [AGE] year-old female diagnosed with acute (sudden) and chronic (long-term) respiratory failure with hypoxia (not enough oxygen in the blood), cerebral infarction (disrupted blood flow to the brain, muscle weakness, and reduced mobility, Record review of the most recent MDS dated [DATE] indicted Resident #1 had a BIMS (brief interview for mental status) score of 12 indicating moderate cognitive impairment. Resident #1 required extensive assistance for bed mobility. During observation on 02/28/22 at 10:15 AM, Resident #1 was awake resting in bed. The corded bed remote control was next to Resident # 1. The cord's plastic insulation coating was damaged in 3 places exposing the wiring underneath. During observation on 02/28/22 at 01:41 PM, Resident #1 was awake resting in bed. The corded bed remote control was next to Resident # 1. The cord's isolation coating was damaged in 3 places exposing the wiring underneath. During observation on 02/28/22 at 3:23 PM, Resident #1 was sleeping in bed. The bed remote cord's plastic insulation coating was damaged in 3 places exposing the wiring underneath During observation on 03/01/22 at 08:18 AM, Resident #1 was awake and eating breakfast in bed. The bed remote control was next to Resident # 1 on the right side. The cord's plastic isolation coating was damaged in 3 places exposing the wiring underneath During interview on 03/02/22 at 08:51 AM, Resident # 1 said she was not aware of the damage to the plastic insulation coating on her bed remote control cord. Resident #1 said did not know if it was disadvantages to her or not. Resident #1 said she could operate the bed remote control independently. During interview on 03/03/22 at 12:45 pm, CNA B said she was familiar with Resident #1, but had not worked with her recently. CNA B said she was not aware of any broken equipment in Resident #1's room. CNA B said damaged equipment would be reported to the charge nurse or put it in the repair book. CNA B said she would unplug the bed remote control if she noticed any damage to the cord. CNA B said a damaged bed remote control cord could possibly shock Resident #1. During interview on 3/3/2022 at 1:05 PM, LVN C said she was the charge nurse for Resident #1 and had not noticed any damaged equipment in her room. LVN C said if she found damaged equipment in a resident's room, she would let the maintenance person know about, or put a request in the repair book. LVN C said Resident #1 could operate the bed remote by herself. LVN C said exposed wiring on the bed remote control could possibly shock Resident #1. LVN C said Resident #1 could possibly get short of breath if the damage caused the bed to get stuck in the flat position. Record review of facility's maintenance request book on 3/3/2022 at 1:05 PM, revealed no requests or repairs regarding Resident #1 bed remote control cord for a time of 12/1/21 through 3/3/22. During interview on 3/3/2022 at 1:16 PM, CNA D said she was familiar and had worked recently with Resident #1. CNA D said she had not noticed any damaged equipment in Resident #1's room. CNA D said she would notify the charge nurse when any damaged equipment was discovered in a resident's room. CNA D said a damaged bed remote control could possibly start a fire. During interview on 3/3/2022 at 1:37 PM, LVN E said she was familiar with Resident # 1 but had not worked with this resident recently. LVN E said if she noted any broken equipment in a resident's room, she would put an entry in the maintenance book, or notify the maintenance person directly. LVN E said damage to Resident #1's bed remote cord could possibly cause her to get shocked. During interview on 3/3/2022 at 1:50 PM, the DON said she works the floors a few times a month and was familiar with Resident #1. The DON said she was not aware of any damage to Resident #1's bed remote control cord. The DON said she does safety rounds of resident rooms, but not every day. The DON said Resident #1's bed remote control was replaced by the housekeeping supervisor on Monday February 28th. The DON said the bed remote control for Resident #1's bed was still operational and did not see a disadvantage to Resident #1. During interview on 3/3/2022 at 4:30 PM, the Housekeeping Supervisor said she was familiar with Resident #1. She said she replaced the bed remote control on Resident #1's bed on Monday (2/28/22). The House Keeping Supervisor said the treatment nurse reported the damaged bed remote control cord on Resident # 1 bed on 2/28/2022. The House Keeping Supervisor said she replaced the bed remote control on Resident #1's bed. The House Keeping Supervisor said the bed remote control on Resident #1's bed would not go up and down. The Housekeeping Supervisor said her housekeepers would report broken equipment found while cleaning resident rooms. The Housekeeping Supervisor said she would replace broken equipment as needed. The House keeping Supervisor said not having a fully operational bed remote control could be detrimental to residents During interview on 3/3/2022 at 4:40 PM, The Administration said she was familiar with Resident #1. The Administrator said she makes safety rounds at least once a week and did so on 2/28/2022. The Administrator said she expected resident equipment to be kept in working order. The Administrator said the facility ensures resident equipment was in good safe operating condition by training staff to report damaged and non-working equipment to her or the maintenance supervisor. The Administrator said Resident #1's bed remote control having exposed wiring on the cord could prevent her from cause Resident #1 to not be able to operate the bed as needed. Record review of website search of the United States Department of Labor Occupational Safety and Health Administration's website https://www.osha.gov/electrical/hazards searched on 3/4/2022 at 9:45 AM revealed: If the electrical conductors (wires) become exposed, there is a danger of shocks, burns, or fire. Replace frayed or damaged cords. Record review of the [NAME] University website search of, https://www.safety.[NAME].edu/sites/default/files/NIOSHElectricalSafetyManualforStudents%2802123%29.pdf on 3/4/2022 at 10:00 AM: Electrical hazards exist when wires or other electrical parts are exposed. Worn, frayed, or damaged insulation around any wire or other conductor is an electrical hazard because the conductors could be exposed. Contact with an exposed wire could cause a shock. Damaged insulation could cause a short, leading to arcing or a fire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 18 residents reviewed for abuse and neglect (Resident #62). The facility did not report bruising caused to both forearms by rough handling of an agency CNA involving Resident #62 to the State within the 2-hour time frame. This failure could place the residents at risk for unreported allegations of abuse, neglect, and injuries of unknown origin. Findings included: Record review of consolidated physician orders dated March 2022 indicated Resident #62 was [AGE] years old, admitted on [DATE] with diagnoses including, hypertension (high blood pressure), muscle wasting and atrophy (loss of muscle tissue), and neuropathy (damage to the nerves). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #62 made self-understood and understands others. The assessment indicated a BIMS score of 12 indicating moderate mental impairment. The assessment indicated Resident #62 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #62 did not have physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #62 required extensive assistance with bed mobility, total dependence with transfers, toilet use, personal hygiene, and bathing and walking did not occur. Record review of the care plan dated 5/9/2016 indicated Resident #62 required staff assistance for all ADLs due to weakness and chronic pain. The care plan indicated Resident #62 needed assistance with dressing, grooming, and oral hygiene and was a two-person transfer with a mechanical lift. The care plan indicated Resident #62 had potential for skin breakdown due to limited mobility and needed assistance to reposition every two hours. The care plan indicated Resident #62 experienced chronic pain in her knees, bilateral arms, and hands related to arthritis and required staff to assist her changing position slowly. The care plan indicated Resident #62 had a grab bar to assist her in repositioning. Record review of a skin assessment dated [DATE] indicated purple bruising to the left forearm measuring 2.9X1.9, purple bruising to the right forearm measuring 4X6, a bruise to the right wrist measuring 1X1, and a bruise to the right thumb area measuring 1X0.5. Units of measurement were not documented. Record review of a skin assessment dated [DATE] completed by the Treatment Nurse indicated a bruise to the right forearm measuring 6X6, a bruise to the right-hand measuring 3X4, and 2 bruises to the left wrist measuring 1.5X1.5. Units of measurement were not documented. During an observation and interview on 02/28/22 at 11:21 a.m., Resident #62 said the outside agency staff were not good. She said they grab her by her arms with gloved hands to move her and pull her over in bed instead of the pad. Resident #62 said she did have an open area that bled to her right forearm. She said it was healed now. Resident #62 pointed to her left and right forearms and faded brown bruising was noted to bilateral arms. Record review of a complaint/grievance report dated 2/14/2022 signed by the DON indicated Resident #62 complained that agency staff member was rough during care with bruise to right forearm. The report indicated the resident did not want to report or make a big deal out of it. The report indicated agency staff member was removed from any further shifts and will no longer be instructed to work. During an interview on 3/01/2022 08:38 a.m., Resident #62 said the staff did come in and question her after she was grabbed by the arms and was told that it would not happen again, the facility had got rid of her. During an interview on 3/01/2022 at 10:24 a.m., The Treatment Nurse said she was notified by Resident #62's family member on 2/13/2022 about the bruising to both of the residents' arms. She said the family member and Resident #62 told her that the agency nurse aids were pulling on her arms to pull her up in bed. The Treatment nurse said the family member was instructed to speak to the Administrator regarding the bruising. She said she was not in the room when the Administrator and the family member spoke, so she could not be sure that the family member reported the bruising to the Administrator. During an interview on 3/01/2022 at 10:39 a.m., The Treatment Nurse said she should have filled out an incident report regarding Resident #62. She said she notified the charge nurse on 2/13/2022 but does not recall who it was. During an interview on 3/01/2022 at 10:42 a.m., LVN G said she was not on shift when the bruising to Resident #62's arms was found. She said she did remember when she returned to work, the staff said it was caused by an agency aids during care. LVN G said she did not recall any other details. During a phone interview on 3/01/2022 at 2:13 p.m., Resident #62's family member said Resident #62 had been bedfast for 6 years. She said she did recall the incident regarding bruising to both forearms of Resident #62. The family member said an agency aide grabbed her arms to position her in bed and left big bruises. She said she took pictures and notified CNA B and the Treatment Nurse. The family member said the Treatment Nurse and CNA B directed her to LVN C and Human Resources. She said she told Human Resources she wanted it documented. The family member said she was then directed to the Administrator and the DON. She said the DON told her it had been addressed and the Agency CNA would not be back in the building. She said she stood in the Administrators office with the DON and notified them of the incident. During an interview on 3/01/2022 at 2:29 p.m., CNA B said Resident #62 told her that someone pulled on her arm and she did not know who, only that it was an Agency CNA. CNA B said she told the nurse that was on duty but does not recall who it was, and CNA B was told by that nurse that it had already been taken care of and reported. CNA B said you report abuse to the Administrator and nurse. She said she recalled staff saying the agency aide was sent home. CNA B said to report abuse immediately. She said she had an abuse in-service last week. She said she does not recall if an in-service was done on Resident #62. CNA B said you should never reposition a resident by pulling on their arms. She said you should use the draw sheet and bed pad. During an interview on 3/03/2022 at 11:15 a.m., the DON said she became aware of bruising on Resident #62's right arm on Sunday (2/13/2022) and that was the only arm she showed her. She said she saw Resident #62 on Monday (2/14/2022) and Resident #62 told her the agency aide rolled her roughly not using a draw sheet. The DON said Resident #62 did not feel like she was intentionally being hurt. She said she asked Resident #62 how she wanted it to be reported and the resident agreed writing a grievance was sufficient as the resident did not want anyone to get in trouble. The DON said she wrote it up on internal grievance report. She said a few days later her family member asked her about the bruising. The DON said LVN P reported the incident to her. The DON said she reported the incident to the Administrator but not on the day she was notified. She said she asked the night nurse to do a skin assessment on her and the DON came in and spoke with her on Monday. The DON said the agency CNA only worked in the facility that shift, had not been back to the facility, and was put on a list to not be allowed back. The DON said she did not want that CNA treating her residents like that. She said Resident #62 was alert and oriented and if she told me she was treating her that way I wouldn't want her to do it to someone else. The DON said agency staff do not sign any paperwork with the facility. She said she assumed the agency vetted the agency staff. She said the facility does not train agency staff and they don't sign off that they received anything. The DON said they do not have any witness or staff statements. She said the incident was not reported to State. During an interview on 3/03/2022 at 1:22 p.m., MA H said you should report abuse to the Administrator, immediately. During an interview on 3/03/2022 at 1:26 p.m., the Treatment Nurse said you should report abuse to the Administrator, immediately. She said in-services on abuse were done regularly. She said she had abuse in-service approximately 2 months ago. The treatment nurse said she would report bruising from staff rough handling a resident. During an interview on 3/03/2022 at 1:30 p.m., MA K said to report abuse to Administrator, immediately. During an interview on 3/03/2022 at 1:34 p.m., CNA M said to report abuse to administrator, immediately. She said if a coherent resident tells you a CNA was rough with them causing bruising, she would find the nurse in charge first and go to the administrator to report it. During an interview on 3/03/2022 at 1:37 p.m., CNA N said she would report abuse to administrator, immediately. She said if a coherent resident told her an aide was rough with them causing bruising, she would report it. During an interview on 3/03/2022 at 1:40 p.m., LVN C said she would report abuse to the Administrator as soon as it is reported to her. She said she would report an incident of an aide being rough with a resident that caused bruising. During an interview on 3/03/2022 at 2:48 p.m., the ADON said she was not working the weekend that Resident #62 obtained bruising to her arms. She said the aide was not allowed to come back to the facility anymore because she did not do proper turning. The ADON said it was not because she was abusive. She said she would report abuse to the administrator immediately. During an interview on 3/03/2022 at 4:09 p.m., The Administrator said she was notified on 2/12/2022 when Resident #62 was complaining about the agency CNA was pulling on her arms instead of the sheets to turn her. She said the agency CNA walked off her shift and did not complete it. The Administrator said Resident #62 did not make an abuse allegation, she was just not happy with her care. She said the next morning which was Monday we met with her. The Administrator said Resident #62 complained that the agency aide did not turn her in bed like our facility staff do. The Administrator said the next week Resident #62's family member came in with pictures of the residents arm. The Administrator said she knew the aide was rough and she was not allowed to come back in the building. She said she did not report it to State. She said Resident #62 never presented it as an allegation or someone trying to be hurtful. The administrator said agency vets their staff and you can access their credentials online. She said the facility was selective on who they choose from Agency and the can ban them from coming. During an interview on 3/03/2022 at 5:13 p.m., The Administrator said she did not speak to Resident #62 directly. She said she asked the DON to talk to Resident #62. The Administrator said if it was an unexplained bruise, she would have investigated it. During a record review of a policy titled Repositioning with a revised date of May 2013 indicated the purpose of this procedure .to promote comfort for all bed- or chair-bound residents .the steps in repositioning a resident in bed included using two people and a draw sheet to avoid shearing while turning or moving the resident up in bed .prevent skin-to-skin contact with use of sheets, pillows, or positioning devices . During a record review of a policy titled Abuse Prevention, Intervention, Investigation, and Reporting dated November 22, 2017 indicated residents are to be free from .abuse .at all times .It is the responsibility of the of employees to promptly report to facility management any incident or suspected incident of .resident abuse .from staff .all reports of possible abuse are promptly and thoroughly investigated by facility management .staff are state mandated reporters and covered individuals (per Elder Justice Act) and must comply with state regulations regarding reporting suspected abuse and with federal regulations regarding reporting any reasonable suspicion of a crime against a resident .physical abuse: non-accidental use of physical force that may result in bodily injury, physical pain .mistreatment: inappropriate treatment .all employees are informed of their responsibility to immediately report any allegation of abuse .to administration for investigation, remediation, and reporting to the appropriate state agency .if the allegation is directed at a non-employee third party, such as a private duty companion, the facility immediately notifies the agency of the allegation .in the event of physical abuse allegations, the DON or designee immediately arranges for a physical examination of the resident .the facility nursing staff conduct an assessment post-allegation with 72-hour monitoring and documentation .all allegation of abuse .are promptly investigated .documentation of the investigation findings are is maintained on applicable forms or reports .activities conducted in the investigation process include as at minimum: review of completed resident abuse report, events and resident records leading up to the incident, personnel records, completion of the following interviews: person reporting the incident, any witnesses to the incident, other residents to whom the accused employee provides care or services, staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .reporting to State Agencies .immediately but no later that 24 hours after the allegation or occurrence .a report of the investigation is provided to the appropriate state agency within five working days of the incident .documentation in the resident medical record includes: identified signs/symptoms and/or resident allegation of abuse, assessment of resident condition, immediate interventions implemented, physician and family notification .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit mistreatment, abuse, neglect, or misappropriation of resident property for 1 of 18 residents reviewed for abuse (Resident #62). The facility did not report immediately to the State agency or thoroughly investigate when an agency CNA rough handled Resident #62 causing bruising to right and left forearms. This failure could place all residents at risk of abuse, neglect, or misappropriation of resident property. Findings included: Record review of consolidated physician orders dated March 2022 indicated Resident #62 was [AGE] years old, admitted on [DATE] with diagnosis including, hypertension (high blood pressure), muscle wasting and atrophy (loss of muscle tissue), and neuropathy (damage to the nerves). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #62 made self-understood and understands others. The assessment indicated a BIMS score of 12 indicating moderate mental impairment. The assessment indicated Resident #62 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #62 did not have physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #62 required extensive assistance with bed mobility, total dependence with transfers, toilet use, personal hygiene, and bathing and walking did not occur. Record review of the care plan dated 5/9/2016 indicated Resident #62 required staff assistance for all ADLs due to weakness and chronic pain. The care plan indicated Resident #62 needed assistance with dressing, grooming, and oral hygiene and was a two-person transfer with a mechanical lift. The care plan indicated Resident #62 had potential for skin breakdown due to limited mobility and needed assistance to reposition every two hours. The care plan indicated Resident #62 experienced chronic pain in her knees, bilateral arms, and hands related to arthritis and required staff to assist her changing position slowly. The care plan indicated Resident #62 had a grab bar to assist her in repositioning. Record review of a skin assessment dated [DATE] indicated purple bruising to the left forearm measuring 2.9X1.9, purple bruising to the right forearm measuring 4X6, a bruise to the right wrist measuring 1X1, and a bruise to the right thumb area measuring 1X0.5. Units of measurement were not documented. Record review of a skin assessment dated [DATE] completed by the Treatment Nurse indicated a bruise to the right forearm measuring 6X6, a bruise to the right-hand measuring 3X4, and 2 bruises to the left wrist measuring 1.5X1.5. Units of measurement were not documented. During an observation and interview on 02/28/22 at 11:21 a.m., Resident #62 the outside agency staff were not good. She said they grab her by her arms with gloved hands to move her and pull her over in bed instead of the pad. Resident #62 said she did have an open are that bled to her right forearm. She said it is healed now. Resident #62 pointed to her left and right forearms and faded brown bruising was noted to bilateral arms. During an interview on 3/01/2022 08:38 a.m., Resident #62 said the staff did come in and question her after she was grabbed by the arms and was told that it would not happen again, the facility had got rid of her. During an interview on 3/01/2022 at 10:24 a.m., The Treatment Nurse said she was notified by Resident #62's family member on 2/13/2022 about the bruising to both of the residents' arms. She said the family member and Resident #62 told her that the agency nurse aids were pulling on her arms to pull her up in bed. The Treatment nurse said the family member was instructed to speak to the Administrator regarding the bruising. She said she was not in the room when the Administrator and the family member spoke, so she could not be sure that the family member reported the bruising to the Administrator. During an interview on 3/01/2022 at 10:39 a.m., The Treatment Nurse said she should have filled out an incident report regarding Resident #62. She said she notified the charge nurse on 2/13/2022 but does not recall who it was. During an interview on 3/01/2022 at 10:42 a.m., LVN G said she was not on shift when the bruising to Resident #62's arms was found. She said she did remember when she returned to work, the staff said it was caused by an agency aids during care. LVN G said she did not recall any other details. During a phone interview on 3/01/2022 at 2:13 p.m., Resident #62's family member said Resident #62 had been bedfast for 6 years. She said she did recall the incident regarding bruising to both forearms of Resident #62. The family member said an agency aide grabbed her arms to position her in bed and left big bruises. She said she took pictures and notified CNA B and the Treatment Nurse. The family member said the Treatment Nurse and CAN B directed her to LVN C and Human Resources. She said she told Human Resources she wanted it documented. The family member said she was then directed to the Administrator and the DON. She said the DON told her it had been addressed and the Agency CNA would not be back in the building. She said she stood in the Administrators office with the DON and notified them of the incident. During an interview on 3/01/2022 at 2:29 p.m., CNA B said Resident #62 told her that someone pulled on her arm and she did not know who, only that it was an Agency CNA. CNA B said she told the nurse that was on duty but does not recall who it was, and CNA B was told by that nurse that it had already been taken care of and reported. CNA B said you report abuse to the Administrator and nurse. She said she recalled staff saying the agency aide was sent home. CNA B said to report abuse immediately. She said she had an abuse in-service last week. She said she does not recall if an in-service was done on resident #62. CNA B said you should never reposition a resident by pulling on their arms. She said you should use to draw sheet and bed pad. During an interview on 3/03/2022 at 11:15 a.m., the DON said she became aware of bruising on Resident #62's right arm on Sunday (2/13/2022) and that was the only arm she showed her. She said she saw Resident #62 on Monday (2/14/2022) and Resident #62 told her the agency aide rolled her roughly not using a draw sheet. The DON said Resident #62 did not feel like she was intentionally being hurt. She said she asked Resident #62 how she wanted it to be reported and the resident agreed writing a grievance was sufficient as the resident did not want anyone to get in trouble. The DON said she wrote it up on internal grievance report. She said a few days later her family member asked her about the bruising. The DON said LVN P reported the incident to her. The DON said she reported the incident to the Administrator but not on the day she was notified. She said she asked the night nurse to do a skin assessment on her and the DON came in and spoke with her on Monday. The DON said the agency CNA only worked in the facility that shift, had not been back to the facility, and was put on a list to not be allowed back. The DON said she did not want that CNA treating her residents like that. She said Resident #62 was alert and oriented and if she told me she was treating her that way I wouldn't want her to do it to someone else. The DON said agency staff do not sign any paperwork with the facility. She said she assumed the agency vetted the agency staff. She said the facility does not train agency staff and they don't sign off that they received anything. The DON said they do not have any witness or staff statements. She said the incident was not reported to State. During an interview on 3/03/2022 at 1:22 p.m., MA H said you should report abuse to the Administrator, immediately. During an interview on 3/03/2022 at 1:26 p.m., the Treatment Nurse said you should report abuse to the Administrator, immediately. She said in-services on abuse at done regularly. She said she had abuse in-service approximately 2 months ago. The treatment nurse said she would report bruising from staff rough handling a resident. During an interview on 3/03/2022 at 1:30 p.m., MA K said to report abuse to Administrator, immediately. During an interview on 3/03/2022 at 1:34 p.m., CNA M said to report abuse to administrator, immediately. She said if a coherent resident tells you a CNA was rough with them causing bruising she would find the nurse in charge first and go to the administrator to report it. During an interview on 3/03/2022 at 1:37 p.m., CNA N said she would report abuse to administrator, immediately. She said if a coherent resident told her an aide was rough with them causing bruising, she would report it. During an interview on 3/03/2022 at 1:40 p.m., LVN C said she would report abuse to the Administrator as soon as it is reported to her. She said she would report an incident of an aide being rough with a resident that caused bruising. During an interview on 3/03/2022 at 2:48 p.m., the ADON said she was not working the weekend that Resident #62 obtained bruising to her arms. She said the aide is not allowed to come back to the facility anymore because she did not do proper turning. The ADON said it was not because she was abusive. She said she would report abuse to the administrator immediately. During an interview on 3/03/2022 at 4:09 p.m., The Administrator said she was notified on 2/12/2022 when Resident #62 was complaining about the agency CNA was pulling on her arms instead of the sheets to turn her. She said the agency CNA walked off her shift and did not complete it. The Administrator said Resident #62 did not make an abuse allegation, she was just not happy with her care. She said the next morning which was Monday we met with her. The Administrator said Resident #62 complained that the agency aide did not turn her in bed like our facility staff do. The Administrator said the next week Resident #62's family member came in with pictures of the residents arm. The Administrator said she knew the aide was rough and she was not allowed to come back in the building. She said she did not report it to State. She said Resident #62 never presented it as an allegation or someone trying to be hurtful. The administrator said agency vets their staff and you can access their credentials online. She said the facility was selective on who they choose from Agency and the can ban them from coming. During an interview on 3/03/2022 at 5:13 p.m., The Administrator said she did not speak to Resident #62 directly. She said she asked the DON to talk to Resident #62. The Administrator said if it was an unexplained bruise, she would have investigated it. During a record review of a policy titled Abuse Prevention, Intervention, Investigation, and Reporting dated November 22, 2017 indicated residents are to be free from .abuse .at all times .It is the responsibility of the of employees to promptly report to facility management any incident or suspected incident of .resident abuse .from staff .all reports of possible abuse are promptly and thoroughly investigated by facility management .staff are state mandated reporters and covered individuals (per Elder Justice Act) and must comply with state regulations regarding reporting suspected abuse and with federal regulations regarding reporting any reasonable suspicion of a crime against a resident .physical abuse: non-accidental use of physical force that may result in bodily injury, physical pain .mistreatment: inappropriate treatment .all employees are informed of their responsibility to immediately report any allegation of abuse .to administration for investigation, remediation, and reporting to the appropriate state agency .if the allegation is directed at a non-employee third party, such as a private duty companion, the facility immediately notifies the agency of the allegation .in the event of physical abuse allegations, the DON or designee immediately arranges for a physical examination of the resident .the facility nursing staff conduct an assessment post-allegation with 72-hour monitoring and documentation .all allegation of abuse .are promptly investigated .documentation of the investigation findings are is maintained on applicable forms or reports .activities conducted in the investigation process include as at minimum: review of completed resident abuse report, events and resident records leading up to the incident, personnel records, completion of the following interviews: person reporting the incident, any witnesses to the incident, other residents to whom the accused employee provides care or services, staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .reporting to State Agencies .immediately but no later that 24 hours after the allegation or occurrence .a report of the investigation is provided to the appropriate state agency within five working days of the incident .documentation in the resident medical record includes: identified signs/symptoms and/or resident allegation of abuse, assessment of resident condition, immediate interventions implemented, physician and family notification .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify and provide needed care and services in accordance with professional standards of practice and comprehensive assessment for 3 of 18 residents reviewed for quality of care. (Residents #32, Resident #55, and Resident #29) The facility failed to assess Resident #32's abdominal wound and did not follow physicians' orders for wound care. The facility failed to assess Resident #55's left lower extremity wound and did not follow physicians' orders for wound care. The facility failed to notify the physician or assess Resident #29's head after he bumped it on his air mattress pump causing the treatment nurse to perform wound care. These failures could place residents at risk for delays in treatments and care which could result in clinical complications, pain, mental anguish, and decreased quality of life. Findings included: 1. Record review of consolidated physician orders, dated March 2022, indicated Resident #32 was [AGE] years old, admitted on [DATE] with diagnoses including, chronic kidney disease (gradual loss of kidney function over time), chronic pain syndrome (Persistent pain that lasts weeks to years), and hypertension (high blood pressure), and disruption of wound, unspecified, sequela (separation of the margins of a closed surgical incision). The physician's orders dated March 2022 indicated to cleanse ostomy (an artificial opening in an organ of the body) site with soap and water. Apply no sting skin prep to peri ostomy site as well as macerated skin. Allow 90 seconds to dry. Apply ostomy bag. Perform every 5 days and as needed if leaking. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #32 made self-understood and understood others. The assessment indicated a BIMS score of 8 and has moderate cognitive impairment. The assessment indicated Resident #32 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment did not indicate if Resident #32 had physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #32 required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Resident #32 was totally dependent for toilet use. She required total dependence for bathing and walking did not occur. The MDS indicated Resident #32 was independent with eating. The assessment indicated Resident #32 had a surgical wound and received surgical wound treatments, application of non-surgical dressings, and applications of ointments/medications. Record review of the care plan dated 8/11/2021 indicated Resident #32 had impaired skin integrity-abdominal fistula and was admitted from the hospital with the wound. The care plan indicated Resident #32 used gauze, abdominal pads, and paper tape for treatment. The goal indicated the wound would decrease in size by next evaluation. The interventions included measuring the wound at least weakly, recording height, width, and length, appearance, amount, and odor of any discharge, and report any decline in wound status to physician. Administer treatments as ordered by physician and document. Record review of hospital records dated 8/27/2021 indicated Resident #32 presented to the emergency room with altered mental status with labs showing acute renal failure. The records indicated that the abdominal wound was not an ostomy and diagnosed as a colocutaneous fistula (a fistulous passage connecting the colon and the skin). The records referred to the fistula as a disaster that needed to go back to the surgeon that created it. The records indicated the patient had infected mesh from a hernia repair that was removed on 5/12/2021 by a surgeon. Record review of a progress note dated 1/25/2022 at 5:15 p.m., indicated Resident #32 had a physicians appointment related to open area to stomach and was sent to the emergency room for evaluation, signed by LVN C. Record review of hospital records dated 1/26/2022 indicated that Resident #32 had a long history of abdominal surgeries with an abdominal infection May 2021 that required an exploratory laparotomy (surgery to open the belly area) and a takedown of enterocutaneous fistula (an abnormal connection that develops between the intestinal tract or stomach and the skin) with repair, and incisional hernia repair. Record review of a progress note dated 2/3/2022 at 12:14 a.m., indicated Resident #32 was re-admitted to the facility with a diagnoses of sepsis (the body's extreme response to an infection), hypotension (low blood pressure), and UTI (urinary tract infection). Record review of skin assessments for Resident #32 indicated: *7/28/2021 Description Fistula; Odor/drainage stool; Treatments daily dressing. There were no wound measurements. *8/4/2021 Size 5x6 (units of measurement not documented) Description open fistula with mesh; Odor/Drainage stomach contents; Treatments ostomy dressing change as needed. *8/9/2021 Description red excoriation abdominal fistula 2X7cm; Odor/Drainage stomach contents; Treatments ostomy dressing change as needed. *8/11/2021 Description abdominal fistula excoriated; Odor/Drainage stomach; Treatments illegible. No measurements were documented. *8/18/2021 Description abdominal fistula; Odor/Drainage Heavy and foul; Treatment dressing change 4 times a day. *8/28/2021 Description: Fistula; Odor/drainage stomach contents; Treatments daily dressing. No wound measurements were documented. *9/2/2021 Size 1.5X1.5 (units of measurement not documented) Description open fistula with excoriation; Odor/Drainage Heavy and foul; Treatment lidocaine and dressing change 4 times a day. *9/17/2021 Size 2X2 Description open fistula with excoriation; Odor/Drainage heavy and foul; Treatment, not documented. *9/26/2021 Description open fistula with excoriation; No Odor/Drainage documented; Treatment abdominal pad dressing. No wound measurements were documented. *10/12/2021 Description abdominal fistula with colostomy bag; Odor/Drainage none; Treatment colostomy bag. No wound measurements were documented. *10/18/2021 Description 1X1 (units of measurement not documented) open with 4X7 excoriation (units of measurement not documented); Odor/Drainage none; Treatment colostomy bag. *11/5/2021 Description fistula; Odor/Drainage bowel movement and fluids; Treatments fistula bag. No wound measurements were documented. *11/11/2021 Description abdominal fistula; Odor/Drainage none; Treatment ostomy bag. No wound measurements were documented. *11/19/2021 Description fistula; Odor/Drainage heavy; Treatment colostomy bag. No wound measurements were documented. *12/2/2021 Description abdominal fistula; Odor/Drainage heavy; Treatment ostomy bag. No wound measurements were documented. *12/9/2021 Description abdominal fistula; Odor/Drainage heavy; Treatment ostomy bag. No wound measurements were documented. *12/17/2021 Description abdominal fistula; Odor/Drainage heavy; Treatment colostomy bag. No wound measurements were documented. *12/23/2021 Description abdominal fistula; Odor/Drainage heavy; Treatment ostomy bag. No wound measurements were documented. *12/30/2021 Description abdominal fistula; Odor/Drainage heavy; Treatment intake and output and ostomy bag. No wound measurements were documented. *1/5/2022 Description abdominal fistula; Odor/Drainage ostomy bag; Treatment intake and output. No wound measurements were documented. *1/12/2022 Description abdominal fistula increased redness; Odor/Drainage heavy; Treatment B. Cream, keep clean dry and intact. No wound measurements were documented. *1/20/2022 Description abdominal fistula; Odor/Drainage heavy; Treatment ostomy bag. No wound measurements were documented. *2/2/2022 Description ostomy site excoriated; Odor/Drainage large; Treatment skin prep ostomy bag. No wound measurements were documented. *2/9/2022 Description excoriation; Odor/Drainage ostomy bag heavy; Treatment ostomy bag skin prep. No wound measurements were documented. *2/24/2022 Description abdominal fistular excoriation; Odor/Drainage heavy; Treatment ostomy bag. No wound measurements were documented. Record review of a treatment administration record dated January 2022 indicated to monitor fistula bag every shift. Clean skin and change bag as needed if leaking. Record review of a treatment administration record dated February 2022 indicated to cleanse ostomy site with soap and water. Apply no sting skin prep to peri ostomy site as well as macerated skin. Allow 90 seconds to dry. Apply ostomy bag. Perform every 5 days and as needed if leaking. Record review of a treatment administration record dated March 2022 indicated to cleanse ostomy site with soap and water. Apply no sting skin prep to peri ostomy site as well as macerated skin. Allow 90 seconds to dry. Apply ostomy bag. Perform every 5 days and as needed if leaking. During an interview on 3/02/2022 at 10:25 a.m., the Treatment Nurse said the area to Resident #32's abdomen was not healed. She said food and undigested food came through the fistula. The Treatment Nurse said she was not retaining her fluids, food, or medications due to them leaking out of the fistula. During an interview on 3/02/2022 at 10:58 a.m., the Treatment Nurse said that she did not have an order to apply tape to the suprapubic area. She said she did not recall when she measured the abdominal wound last. The Treatment Nurse said the abdominal wound would not heal. She said the ostomy bag had a hard time sealing and leaked causing excoriation to the surrounding area. During a phone interview on 3/02/2022 at 1:15 p.m., the surgeon's nurse said Resident #32 diagnosis was enterocutaneous fistula (abnormal communication between the small or large bowel and the skin). She said the surgeon's notes indicated the resident should remain on Imodium (Antidiarrheal), Lomotil (Antidiarrheal), and Metamucil (Laxative - Bulk Forming) and the wound care must be diligent. She said a follow up consultation for Resident #32 had not been made by the facility as requested by the surgeon. During an observation and interview on 3/02/2022 at 2:17 p.m., the Treatment Nurse provided wound care to Resident #32's abdominal wound. She removed an undated large piece of tape from the lower abdomen/suprapubic area that revealed a red excoriated area underneath. The Treatment Nurse said she was not aware the area was excoriated. She said the new excoriated area measured 2.5X0.2cm. She said she did not have an order to apply the tape to the area. The tape was saturated with brown fluid. The Treatment Nurse said she had to apply the tape because it was the only way she could get the ostomy bag to stick. The tape was attached to the ostomy bag. The Treatment Nurse removed the undated colostomy bag containing a thick yellow and brown substance and wiped the large red excoriated area and fistula with a Reassure Cleansing cloth that contained lanolin and aloe vera. She then applied sure prep to the excoriated area and applied the ostomy bag. She said the red excoriated area measured 7.5X7.0cm and the fistula measured 0.5X0.5cm. The Treatment Nurse said she had spoken with the surgeon's office multiple times about the wound not healing but did not document it. During an interview on 3/02/2022 at 3:10 p.m., the Treatment Nurse said if a wound was not healing the physician should be notified. During a phone interview on 3/02/2022 at 4:32 p.m., the General Surgeon said Resident #32 came to him with an infected mesh protruding through the abdomen from a previous bariatric surgery. He said Resident #32 was sent back to the facility with a wound vac which caused a hole in her small intestine resulting in an enterocutaneous fistula. He said on the first follow up visit after surgery, Resident #32 was not a surgical candidate to repair the fistula because the facility was not giving the resident the medication he prescribed to bulk up the fistula contents which included Imodium, Lomotil, and Metamucil. The General Surgeon said he expected Resident #32 to be on those medications at the maximum doses indefinitely. He said he did not recall why the facility was not giving the resident the medications. The General Surgeon said on the scheduled second follow up visit the resident was sent to the emergency room for hypotension, signs of dehydration and lethargy. He said the facility was giving the prescribed medications at that time. The General Surgeon said he was more than happy to educate the facility staff on how to care for Resident #32's enterocutaneous fistula and the wound surrounding it. He said the facility had not reached out to make another appointment. During an interview on 3/03/2022 at 11:15 a.m., the DON said open wounds should be measured weekly. She said staff would not be able to determine if a wound was healing if there were no measurements or descriptions. The DON said she expected staff to follow physicians' orders. During an interview on 3/03/2022 at 12:39 p.m., LVN E said the charge nurse was responsible for wound care if they did not have a treatment nurse. She said as the charge nurse she should know what residents' wounds look like. LVN E said they need an order for wound care and physician's orders should be followed. She said if physicians' orders were not followed, the wound could get worse or infected. LVN E said wounds should be measured weekly. She said a nurse would not know if a wound was worse or better without wound measurements. During an interview on 3/03/2022 2:48 p.m., the ADON said wound measurements should be done weekly with skin assessments. She said staff should follow physicians' orders for wound care. The ADON said the charge nurse was responsible for treatments when the treatment nurse was not available. She said wounds should be care planned. The ADON said staff needed a physician's order to treat a wound. She said staff could not monitor a wound without documentation. The ADON said staff would not know if a wound was healing if it did not have measurements. 2. Record review of consolidated physician orders dated March 2022 indicated Resident #55 was [AGE] years old, readmitted on 1/06/2020 with diagnoses including, hypotension (low blood pressure), encephalopathy (damage or disease that affects the brain), and convulsions (abnormal violent and involuntary contraction of muscles). The physician's orders did not indicate an order for wound care. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #55 made self-understood and understood others. The assessment indicated a BIMS score of 9 and had moderately impaired cognition. The assessment indicated Resident #55 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment did not indicate if Resident #55 had physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #55 required limited assistance with bed mobility, transfers, toilet use, and personal hygiene. He required physical help in part of bathing and walking did not occur. The assessment indicated Resident #55 had moisture associated skin damage and used applications of ointments/medications. Record review of the care plan dated 1/27/2021 indicated Resident #55 required minimum staff assistance for ADLs. The care plan did not indicate Resident #55 had a wound. Record review of the treatment administration record dated February 2022 indicated to cleanse open areas to left lower extremity with normal saline, pat dry, and apply a dry dressing every shift with date ordered 2/11/2022. The treatment was signed that the treatment had been completed for the 7am-7pm and 7pm-7am shifts on dates 2/26/2022 and 2/27/2022. Record review of the treatment administration record dated March 2022 indicated to cleanse open areas to left lower extremity with normal saline, pat dry, and apply a dry dressing every shift (7am-7pm and 7pm-7am) with date ordered 2/11/2022. Record review of skin assessments for Resident #55 indicated: *2/16/2022 Size 6X5 (no units of measurement documented) Description open abrasion; Odor/Drainage none; Treatment normal saline triple antibiotic ointment dressing. Documented by the Treatment Nurse. *2/23/2022 Size 2X3.2 (no units of measurement documented) Description open abrasion; Odor/Drainage none; Treatment normal saline triple antibiotic ointment kerlix. Documented by the Treatment Nurse. *3/2/2021 Size 7X3 (no units of measurement documented) Description no open with pink skin; Odor/Drainage none; Treatment healed monitor. Documented by the Treatment Nurse. During an observation and interview on 2/28/22 at 10:03 a.m. revealed Resident #55 had a wound dressing dated 2/25/2022 to his left lower leg. He said he bumped his leg on the wheelchair when he was getting out of bed. During an interview on 2/28/2022 at 2:06 p.m., Resident #55 said staff did not change the bandage to his left lower extremity more than once a day. During an observation on 3/01/2022 at 8:26 a.m., Resident #55 was sitting up in his wheelchair watching television with no wound dressing noted to his left lower extremity. Small yellow crusty areas were noted. During an observation and interview on 3/01/2022 at 9:52 a.m., the Treatment Nurse said the last time she changed Resident #55's dressing to his left lower extremity was yesterday 2/28/2022. She said the old dressing that she removed was dated 2/25/2022. The Treatment Nurse said she worked Monday through Friday and the facility had a different treatment nurse on the weekends and the weekend treatment nurse got pulled to work nights. The Treatment Nurse said the charge nurses were responsible for treatments when there was no treatment nurse. She said the dressing to Resident #55 left lower extremity should have been changed as ordered. The Treatment Nurse said the wound could worsen or get infected if not treated. She measured Resident #55's left lower extremity during this time and said the wound measured 1.5 X 2cm. During an observation and interview on 3/1/2022 at 10:05 a.m., the Treatment Nurse measured Resident #55 left lower extremity wound and said the redness measured 11X8cm and the area she was treating measured 1.5X2cm. 3. Record review of consolidated physician orders dated March 2022 indicated Resident #29 was [AGE] years old, admitted on [DATE] with diagnoses including, hypertension (high blood pressure), encephalopathy (damage or disease that affects the brain), and acute kidney failure (abrupt decrease in kidney function). The physician's orders did not indicate an order for wound care. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #29 made self-understood and understood others. The assessment indicated a BIMS score of 4 and had severely impaired cognition. The assessment indicated Resident #29 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #29 did not have physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #29 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The assessment indicated Resident #29 totally dependent for toilet use and bathing and walking did not occur. Record review of the care plan dated 3/31/2021 indicated Resident #29 required moderate staff assistance for all ADLs due to weakness and fracture to right hand. The care plan did not indicate Resident #29 had a wound. Record review of the treatment administration record dated January, February, and March 2022 did not indicate a wound or treatment to a wound to Resident #29's left forehead. Record review of skin assessment for January 2022, February 2022, and March 2022 did not indicate a wound to Resident #29's left forehead. During an observation and interview on 2/28/2022 at 10:50 a.m. revealed Resident #29 was sitting up in his wheelchair and had steri-stips to left forehead, Resident #29 said he hit his head in the shower. During an interview on 3/01/2022 at 9:28 a.m., LVN G said she was Resident #29's nurse was not aware Resident #29 had steri-strips on his left forehead. She said she does not know what happened to his forehead. During an interview on 3/01/2022 at 9:29 a.m., the Treatment said she does not know what happened to Resident #29's head. She said there were no progress notes and no incident report regarding the wound to his left forehead. The Treatment Nurse said an incident report should have been written. During an observation and interview on 3/01/2022 at 9:30 a.m., the Treatment Nurse walked into Resident #29's room and said it looked like a piece of tape was placed on the resident's forehead. During an interview on 3/01/2022 at 9:31 a.m., CNA B said Resident #29 hit his head on the air mattress pump when he was being positioned in bed. She said Resident #29 was too high up in the bed when he was rolled over and he hit his forehead causing a wound. CNA B said she told the Treatment Nurse and LVN C when it occurred. During an interview on 3/01/2022 9:33 a.m., the Treatment Nurse said she did recall CNA B telling her about Resident #29 hitting his head and she cleaned the area with normal saline, patted dry, and applied steri-strips to the area. She said she did not write an order for the treatment and she did not have an order for treatment. The Treatment Nurse said she should have written the order, documented the wound on the treatment sheet, and filled out an incident report. She said she did not notify the physician. During an interview on 3/01/2022 at 10:05 a.m., LVN G said the charge nurse was responsible for wound care if they did not have a treatment nurse. She said an order should be carried out as written. LVN G said if a dressing was not changed as ordered the resident would be at risk for infection or worse. She said the physician should be notified of a new wound. She said if staff were unaware of a wound they would not be able to assess and treat it which could cause infection or worse. During an interview on 3/3/2022 at 11:15 a.m., the DON said she expected staff to follow physicians' orders. She said the charge nurse was responsible for treatments when the treatment nurse was not available. She said she expected the charge nurses to know what their residents wound looked like and how they were progressing, and this should be part of the nursing assessment. The DON said the weekend treatment nurse was responsible for wound care on the weekends. She said the weekend treatment nurse was currently assigned to the floor on weekend and the charge nurses were responsible for weekend wound care. The DON said nurses could access wound care education on their internal education system. She said it was not part of mandatory training. The DON said the facility did not require staff to be wound care certified and the staff was free to do any additional wound education they wanted to. She said the facility used a traveling wound care physician, but they did not call him often. She said wounds should be care planned. During an interview on 3/03/2022 at 12:39 p.m., LVN E said the charge nurse was responsible for wound care if they do not have a treatment nurse. She said as the charge nurse she should know what her resident's wounds look like. She said she would notify the physician if someone hit their head and she would fill out an incident report. LVN E said if it resulted in a wound it should go on the treatment sheet to be monitored. LVN E said a physician's order was needed for wound care. She said physicians' orders should be followed. She said she would not know to monitor a wound if was not documented and the wound could get worse or infected without monitoring. LVN E said wounds should be measured weekly and staff would not be able to determine if the wound had improved or declined without wound measurements. During an interview on 3/03/2022 at 2:48 p.m., the ADON said measurements should be done weekly with skin assessments. She said staff should follow physicians' orders for wound care. She said the charge nurse was responsible for treatments when the treatment nurse was not available. The ADON said wounds should be care planned. She said an incident report should filled out when a resident hit their head causing a wound and the physician should be notified. The ADON said staff would need a physician's order to treat a wound. She said all wounds should be put on a treatment record and skin assessment. She said staff could not monitor a wound without documentation and the wound could become infected or deteriorate. The ADON said staff would not know if a wound was healing if it did not have measurements. The ADON said she only looked at the wounds in the building when she was the charge nurse, and the treatment was due. During an interview on 3/03/2022 at 4:09 p.m., the Administrator said she expected staff to follow wound care protocols and to follow physician orders. She said if orders were not followed, the wound could have an adverse reaction. The Administrator said she didn't think an order would be needed for everything and she expected staff to use nursing judgement for wound care. She said a wound or anything on the skin should be monitored. The Administrator said the charge nurse was responsible for treatments if the treatment nurse was gone. She said depending on the severity of the issue or wound, the physician may or may not need to be notified. She said, our physicians have said they don't want to be bothered for small things like bruises. During a record review of a Wound Care policy with a revised date of October 2010 indicated to verify that there is a physician's order for this procedure .review the resident's care plan to assess for any special needs of the resident .for example, the resident may have PRN orders for pain medication to be administered prior to wound care .mark tape with initials, time, and date and apply dressing .the following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, any change in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when assessing the wound .how the resident tolerated the procedure . During a record review of a policy titled Dressing, Dry/Clean with a revised date of February 2014 indicated to verify that there is a physician's order for this procedure .review the resident's care plan to assess for any special needs of the resident .for example, the resident may have PRN orders for pain medication to be administered prior to wound care .mark tape with initials, time, and date and apply dressing .the following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, any change in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when assessing the wound .how the resident tolerated the procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 18 residents reviewed for pain management. (Resident #32) The Treatment Nurse failed to stop wound care and notify the nurse when Resident #32 complained of pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Record review of consolidated physician orders dated March 2022 indicated Resident #32 was [AGE] years old, readmitted on [DATE] with diagnoses including, chronic kidney disease (gradual loss of kidney function over time), chronic pain syndrome (Persistent pain that lasts weeks to years), and hypertension (high blood pressure). The physician's orders indicated Resident #32 was ordered Gabapentin 100mg 3 times a day for chronic pain syndrome ordered 2/3/2022, Hydrocodone 7.5mg/325 every 6 hours as needed for pain ordered 2/03/2022, and Tylenol 650mg every 6 hours as needed for mild pain ordered 2/2/2022. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #32 made self-understood and understood others. The assessment indicated a BIMS score of 8 and had moderately impaired cognition. The assessment indicated Resident #32 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment did not indicate if Resident #32 had physical or verbal behavior symptoms directed toward others. The assessment indicated Resident #32 received a scheduled pain mediation regimen and received as needed pain medication. The assessment indicated Resident #32 had a presence frequent presence of pain that caused limited day to day activities. The assessment indicated a numeric pain assessment of a 6 on a scale of 0-10 (zero being no pain and 10 being worst pain). The assessment indicated Resident #32 had surgical wound care, application of nonsurgical dressings, and applications of ointments/medications. Record review of the care plan dated 8/11/2021 indicated Resident #32 experienced frequent pain and had as needed medication available. The interventions indicated to administer pain medications as ordered. The care plan indicated that Resident #32 had impaired skin integrity -abdominal fistula. Record review of Resident #32's medication administration record dated 3/2/2022 indicated Resident #32 received Gabapentin 100mg at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The record did not indicate that Resident #32 received Tylenol or Hydrocodone on 3/2/2022. Record review of Resident #32's physicians orders indicated a pain assessment every shift. (7am-7pm and 7pm-7am). The order was dated 2/3/2022. Record review of Resident #32's treatment administration record dated February 2022 and March 2022 did not indicate an assessment for pain. Record review of Resident #32's medication administration record dated February 2022 and March 2022 did not indicate an assessment for pain. Record review of Resident #32's physicians orders dated March 2022 with an order date of 2/2/2022 indicated cleanse ostomy site with soap and water. Apply no sting skin prep to peri ostomy site as well as macerated skin. Allow 90 seconds to dry. Apply ostomy bag. Perform every 5 days and as needed if leaking. During observation and interview on 3/02/2022 at 2:17 p.m., the Treatment Nurse provided wound care to Resident #32's abdominal wound. As the Treatment Nurse was cleansing Resident #32's abdominal wound, Resident #32 was blowing out of her mouth, grimacing, and pushing the treatment nurses' hands away from her abdomen area. Resident #32 said that hurts. The Treatment Nurse said, I know, I'm sorry and placed Resident #32 hands above her abdominal wound on her chest and said, I have to finish this first. During an interview on 3/02/2022 at 3:10 p.m., The Treatment Nurse said she would not give Resident #32 pain medication prior the wound care because she gets pain medication routinely. She said she believed Resident #32 received Ultram for pain on schedule. During an interview on 3/03/2022 at 11:15 a.m., the DON said she expected staff to administer pain medication before painful treatments. She said she expected staff to stop a treatment if it caused pain and staff should check to see if that resident can have pain medication. During an interview on 3/03/2022 at 12:39 p.m., LVN E said she would medicate residents before performing painful wound care. During an interview on 3/03/2022 at 2:48 p.m., The ADON said if resident had a painful treatment, she would medicate the resident prior to performing wound care. She said if it was painful during the treatment, she would stop the wound care and medicate the resident and come back. During an interview on 3/03/2022 at 4:09 p.m., The Administrator said she expected staff to follow wound care protocols to follow physician orders. She said she expected staff to stop wound care if it was hurting a resident. During a record review of a policy titled Pain - Clinical Protocol with a revised date of March 2018 indicated The physician and staff will identify individuals who have pain or who are at risk for having pain .this includes reviewing known diagnoses and conditions that commonly cause pain .the staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 1 of 18 residents reviewed for storage of medications (Resident #52). The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #52 had unlabeled medications in a plastic pill cup on her bedside table. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: Record review of consolidated physician orders dated March 2022 indicated Resident #52 was [AGE] years old, admitted [DATE] with diagnoses including hypertension (force of the blood against the artery walls is too high), venous insufficiency (failure of the veins to adequately circulate the blood), and cardiac arrhythmia (irregular heartbeat). Further review of the physician orders indicated Resident #52 was ordered to receive amlodipine 5mg daily ordered 3/5/2021 for atrioventricular block, Aspirin 81mg daily ordered 3/5/2021 for unspecified fracture lower end of femur, lisinopril 20mg daily ordered 3/5/2021 for hypertension, Occuvite Adult 50 daily ordered 3/5/2021, Vitamin C 500mg daily ordered 3/8/2021, Vitamin D 2000iu daily ordered 3/8/2021, Zinc 50mg daily ordered 3/8/2021, Omeprazole 20mg daily ordered 7/1/2021, trazodone 50mg nightly ordered 3/15/2021, Turmeric complex 1000mg twice daily ordered 3/15/2021, multi-mineral vitamin 600mg twice a day ordered 4/9/2021. Record review of the comprehensive MDS dated [DATE] indicated Resident #52 made herself understood and understands others. The assessment indicated a BIMS score of 14 and had intact cognition. The assessment indicated Resident #52 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment indicated Resident #52 did not have physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #52 required extensive assistance with bed mobility, total dependence with transfers, toilet use, personal hygiene, and bathing and walking did not occur. Record review of a care plan dated 3/24/2021 indicated Resident #52 had a potential for drug toxicity due to taking trazodone. The interventions included monitoring for side effects and effectiveness. The care plan indicated that Resident #52 chose to self-administer eye drops. The care plan does not address self-administering or oral medications. During an observation and interview on 2/28/2022 at 10:11 a.m., this surveyor entered Resident #52's room on initial tour and saw a plastic medication cup filled with multiple medication on the bedside table prior to MA Q entering the room. MA Q entered Resident #52's room several minutes later and picked the plastic pill cup filled with numerous medications sitting on the bedside table stating she had to finish what she started. Resident #52 said she would take them later. MA Q took the pill cup with medications and left the room and stated she would be back. During an interview on 3/03/2022 at 11:15 a.m., the DON said Resident #52 can self-administer eye drops and was care planned for it. She said there was not an order to keep Resident #52's medication at the bedside. The DON said there must be an order to self-administer medications. She said staff should not leave medications at the bedside. The DON said there was no way to monitor if the resident took the medications if they were left at the bedside. She said there was risk of another resident taking those medications. During an interview on 2/28/2022 at 11:45 a.m., MA Q said she had gone in Resident #52's room and a family member called the resident and Resident #52 said she would take them later, so she left them on the bedside table. MA Q said Resident #52 was independent and demanding. MA Q said she left Resident #52's medications at her bedside often. MA Q said the medications in the plastic cup included turmeric, occuvite, lisinopril 20mg, Norvasc 5mg, vitamin C, vitamin D, zinc, calcium 600mg, aspirin 81mg, omeprazole 20mg. Ma Q said it was not a normal practice to leave medications at the bedside. She said it was not appropriate to leave them at the beside because the resident could have wasted them or the resident could not have taken them, or another resident could have come in her room and taken them. During an interview on 3/03/2022 at 12:33 p.m., Resident #52 said she knew what most of her pills looked like and knew what some of them were for but could not identify all of them. She said she had a general knowledge and knew if something was off just by looking at her medication. Resident #52 said she could only name a few of her medications. She said the medication aides would leave medication on her bedside table occasionally. During an interview on 3/03/2022 at 12:39 p.m., LVN E said it was not appropriate to leave medications at the beside. She said you would not know if the resident took them or if someone else took them. LVN E said the facility has wanderers. During an interview on 03/03/2022 at 1:22 p.m., MA H said it was not appropriate to leave medication at bedside. She said someone else could take it and you would not know if they took their medication or not. During an interview on 3/03/2022 at 1:30 p.m., MA K said it was not appropriate to leave a cup of medication at the bedside. She said the resident could not take the medication or someone else could enter the room and take them. MA K said the resident could drop it and not know what they dropped it. During an interview on 3/03/2022 at 2:48 p.m., The ADON said medications should never be left at the bedside because another resident could take them or that resident may not take them. During an interview on 3/03/2022 at 4:09 p.m., The Administrator said medications should not be left at the bedside because of adverse reactions, missed doses, or another resident could enter and take them. Record review of a policy titled Administering Medications with a revised date of April 2019 indicated mediations are administered in a safe and timely manner, and as prescribed .medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions .for residents not in their rooms or otherwise unavailable to receive medication on the pass, the record may be flagged .after completing the medication pass, the nurse will return to the missed resident to administer the medication .residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . Record review of a policy titled Self-Administration of Medications with a revision date of December 2016 indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .if the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assist 1 of 18 residents reviewed for dental concerns in obtaining routine dental care. (Resident #55) The facility did not assist Resident #55 to obtain dental services when he had dentures that did not fit. This failure could place residents at risk of not having their oral health care needs met. Findings included: Record review of the consolidated physician orders dated March 2022 indicated Resident #55 was [AGE] years old, readmitted on 1/06/2020 with diagnoses including, hypotension (low blood pressure), encephalopathy (damage or disease that affects the brain), and convulsions (abnormal violent and involuntary contraction of muscles). The physicians orders indicated Resident #55 was on a regular, NAS, NSC diet ordered 5/31/2020. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #55 made self-understood and understood others. The assessment indicated a BIMS score of 9 and had moderately impaired cognition. The assessment indicated Resident #55 did not reject care necessary to achieve the resident's goals for health or well-being. The assessment did not indicate if Resident #55 had physical or verbal behavior symptoms directed toward others. The MDS indicated Resident #55 required limited assistance with bed mobility, transfers, toilet use, and personal hygiene. He required physical help in part of bathing and walking did not occur. Resident #55 required supervision with eating. The MDS assessment indicated Resident #55 had no natural teeth or tooth fragments. Record review of progress notes for Resident #55 dated 1/10/2022 to 2/26/2022 did not indicate concerns regarding dentures. Record review of the care plan dated 1/22/2020 indicated Resident #55 wore dentures. The goal of the care plan indicated the resident would not have any problems from dentures by next evaluation. The care plan interventions included: place dentures in resident's mouth before meals, remove resident's dentures before bedtime, and refer to dentist/dental hygienist for evaluation and recommendations. The care plan indicated Resident #55 ate a NAS (no added salt) and NCS (no concentrated sweets) diet. During an observation and interview on 03/01/2022 at 3:08 p.m., Resident #55 was not wearing denture and does not have any teeth. He said his dentures were in his drawer and they do not fit. Resident #55 said he would like them fixed and has told staff several times, but they have not done anything. He said he could not eat certain foods and he knew what he could and could not eat. During an interview on 3/03/2022 at 12:56 p.m., CNA R said she normally took care of Resident #55 and was aware his dentures did not fit. She said they have not fit for a week. CNA R said she did not tell anyone that Resident #55's dentures did not fit. She said she has been working here for 17 years. During an interview on 3/03/2022 at 1:00 p.m., Resident #55 said his dentures have not fit for several years. He said they wobble around in his mouth. Resident #55 said he has not worn them pretty much since day 1. During an interview on 3/03/2022 at 2:48 p.m., The ADON said she did not know if Resident #55 wore dentures or not. She said she had not been told Resident #55's dentures did not fit. The ADON said the CNA was responsible for telling charge nurse if dentures do not fit. She said the denture could rub the resident's gums, they might not be able eat certain foods, or experience weight loss if they couldn't eat. During an interview on 3/03/2022 at 3:05 p.m., The DON said she did not know that Resident #55's dentures did not fit. She said she had not seen him wearing dentures. She said if denture did not fit, it should be reported to the social worker. She said the facility has not had any issues since Covid-19 getting dental in the building. She said Mobile Dental visits the facility routinely and there were no issues getting dentures. The DON said not having dentures could limit residents eating certain types of foods. She said Resident #55 did not have problem eating Cheetos and hot fries without dentures. During an interview on 3/03/2022 3:12 p.m., The Social Worker Intern said she would expect staff to tell her if a patient needed dentures fixed. She has not been notified that Resident #55's dentures did not fit. The Social Worker Intern said the facility did not have difficulty getting dental care in the building. She said she did not have a dental referral for Resident #55 for Mobile Dental. During an interview on 3/03/2022 at 4:09 p.m., The Administrator said she was not aware Resident #55's dentures did not fit. She said she would expect staff to report if a resident's dentures did not fit. The Administrator said Mobile Dental visits the facility regularly and they have had no issues getting dental services. During an interview on 3/03/2022 at 4:38 p.m., The Social Worker said she had been out on maternity leave for that past couple weeks. She said she was not aware that Resident #55 needed new dentures or that his dentures did not fit. Record review of a policy titled Dental Services with a revised dated of December 2016 indicated routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .social service representatives will assist residents with appointments, transportation arrangements .direct care staff will assist residents with denture care, including removing, cleaning, and storing dentures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, functional, and comfortable environment for 1 of 14 residents (Resident #1), reviewed for a homelike environment. The facility failed to ensure Resident #1 had a bed remote control cord in safe operating condition. This failure could place residents at risk for injury and a diminished quality of life due to environment. The findings included: Record review of Resident #1's face sheet dated 3/03/2022 revealed an original facility admission date on 2/18/2019 and a re-admission date on 1/06/2021. Resident #1 was a [AGE] year-old female diagnosed with acute (sudden) and chronic (long-term) respiratory failure with hypoxia (not enough oxygen in the blood), cerebral infarction (disrupted blood flow to the brain, muscle weakness, and reduced mobility, Record review of the most recent MDS dated [DATE] indicted Resident #1 had a BIMS (brief interview for mental status) score of 12 indicating moderate cognitive impairment. Resident #1 required extensive assistance for bed mobility. During observation on 02/28/22 at 10:15 AM, Resident #1 was awake resting in bed. The corded bed remote control was next to Resident # 1. The cord's plastic insulation coating was damaged in 3 places exposing the wiring underneath. During observation on 02/28/22 at 01:41 PM, Resident #1 was awake resting in bed. The corded bed remote control was next to Resident # 1. The cord's isolation coating was damaged in 3 places exposing the wiring underneath. During observation on 02/28/22 at 3:23 PM, Resident #1 was sleeping in bed. The bed remote cord's plastic insulation coating was damaged in 3 places exposing the wiring underneath During observation on 03/01/22 at 08:18 AM, Resident #1 was awake and eating breakfast in bed. The bed remote control was next to Resident # 1 on the right side. The cord's plastic isolation coating was damaged in 3 places exposing the wiring underneath During interview on 03/02/22 at 08:51 AM, Resident # 1 said she was not aware of the damage to the plastic insulation coating on her bed remote control cord. Resident #1 said did not know if it was disadvantages to her or not. Resident #1 said she could operate the bed remote control independently. During interview on 03/03/22 at 12:45 pm, CNA B said she was familiar with Resident #1, but had not worked with her recently. CNA B said she was not aware of any broken equipment in Resident #1's room. CNA B said damaged equipment would be reported to the charge nurse or put it in the repair book. CNA B said she would unplug the bed remote control if she noticed any damage to the cord. CNA B said a damaged bed remote control cord could possibly shock Resident #1. During interview on 3/3/2022 at 1:05 PM, LVN C said she was the charge nurse for Resident #1 and had not noticed any damaged equipment in her room. LVN C said if she found damaged equipment in a resident's room, she would let the maintenance person know about, or put a request in the repair book. LVN C said Resident #1 could operate the bed remote by herself. LVN C said exposed wiring on the bed remote control could possibly shock Resident #1. LVN C said Resident #1 could possibly get short of breath if the damage caused the bed to get stuck in the flat position. Record review of facility's maintenance request book on 3/3/2022 at 1:05 PM, revealed no requests or repairs regarding Resident #1 bed remote control cord for a time of 12/1/21 through 3/3/22. During interview on 3/3/2022 at 1:16 PM, CNA D said she was familiar and had worked recently with Resident #1. CNA D said she had not noticed any damaged equipment in Resident #1's room. CNA D said she would notify the charge nurse when any damaged equipment was discovered in a resident's room. CNA D said a damaged bed remote control could possibly start a fire. During interview on 3/3/2022 at 1:37 PM, LVN E said she was familiar with Resident # 1 but had not worked with this resident recently. LVN E said if she noted any broken equipment in a resident's room, she would put an entry in the maintenance book, or notify the maintenance person directly. LVN E said damage to Resident #1's bed remote cord could possibly cause her to get shocked. During interview on 3/3/2022 at 1:50 PM, the DON said she works the floors a few times a month and was familiar with Resident #1. The DON said she was not aware of any damage to Resident #1's bed remote control cord. The DON said she does safety rounds of resident rooms, but not every day. The DON said Resident #1's bed remote control was replaced by the housekeeping supervisor on Monday February 28th. The DON said the bed remote control for Resident #1's bed was still operational and did not see a disadvantage to Resident #1. During interview on 3/3/2022 at 4:30 PM, the Housekeeping Supervisor said she was familiar with Resident #1. She said she replaced the bed remote control on Resident #1's bed on Monday (2/28/22). The House Keeping Supervisor said the treatment nurse reported the damaged bed remote control cord on Resident # 1 bed on 2/28/2022. The House Keeping Supervisor said she replaced the bed remote control on Resident #1's bed. The House Keeping Supervisor said the bed remote control on Resident #1's bed would not go up and down. The Housekeeping Supervisor said her housekeepers would report broken equipment found while cleaning resident rooms. The Housekeeping Supervisor said she would replace broken equipment as needed. The House keeping Supervisor said not having a fully operational bed remote control could be detrimental to residents During interview on 3/3/2022 at 4:40 PM, The Administration said she was familiar with Resident #1. The Administrator said she makes safety rounds at least once a week and did so on 2/28/2022. The Administrator said she expected resident equipment to be kept in working order. The Administrator said the facility ensures resident equipment was in good safe operating condition by training staff to report damaged and non-working equipment to her or the maintenance supervisor. The Administrator said Resident #1's bed remote control having exposed wiring on the cord could prevent her from cause Resident #1 to not be able to operate the bed as needed. Record review of website search of the United States Department of Labor Occupational Safety and Health Administration's website https://www.osha.gov/electrical/hazards searched on 3/4/2022 at 9:45 AM revealed: If the electrical conductors (wires) become exposed, there is a danger of shocks, burns, or fire. Replace frayed or damaged cords. Record review of the [NAME] University website search of, https://www.safety.[NAME].edu/sites/default/files/NIOSHElectricalSafetyManualforStudents%2802123%29.pdf on 3/4/2022 at 10:00 AM: Electrical hazards exist when wires or other electrical parts are exposed. Worn, frayed, or damaged insulation around any wire or other conductor is an electrical hazard because the conductors could be exposed. Contact with an exposed wire could cause a shock. Damaged insulation could cause a short, leading to arcing or a fire.