**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #262) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #262's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #262's electronic face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included Syncope (fainting) and Collapse, Hypertensive urgency (high blood pressure), Nonrheumatic Mitral Valve Disorder (mitral valve does not close properly, allowing blood to flow backwards into the heart), Atrioventricular Block first degree (a condition where the hearts wiring was slow to send electrical signals), Paroxysmal Atrial Fibrillation (episodes of irregular heartbeat), and Somnolence (a state of drowsiness or strong desire to fall asleep). Record review of Resident #262's BIMS dated [DATE],5 revealed she scored a 15, which indicated she was cognitively intact. Record review of Resident #262's care plan revealed, Resident #262 was a DNR. Interventions: Ensure signed DNR was in medical record. If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification. Keep resident as comfortable as possible at all times. [NAME] chart and all pertinent documents with DNR status. Send copy of DNR paperwork upon transfer from facility. Social services consult if resident/family want to change code status. Record review of Resident #262's physician order dated [DATE] revealed, DNR (Do Not Resuscitate). Record review of Resident #262's OOH-DNR form dated [DATE] revealed the form was signed in section A. Declaration of the adult person: I am competent and at least [AGE] years of age. I direct that none of the following resuscitation measures be initiated or continued for me: cardiopulmonary resuscitation (CPR), transcutaneous cardia pacing, defibrillation, advanced airway management, artificial ventilation. The OOH-DNR revealed the form was not signed by the attending physician in section: Physician's Statement: I am the attending physician of the above noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in our-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. It also revealed the physician did not sign below in the last section All persons who have signed above must sign below, acknowledging that this document has been properly completed. In an interview on [DATE] at 10:44 a.m. with SS, she stated upon admission when doing the initial social history, she informed the resident and/or family of their rights regarding the DNR. She explained the difference between DNR and full code. She explained the risks involved when receiving CPR. If it were requested for the resident to be a DNR, she provided them with the form, and obtained their signatures. SS stated that she has been trained to have DNR form completed within 24 hours. She stated the DNR form was placed in a binder at the nurse's station, even if form was incomplete, missing MD signature. She puts the original DNR form in the MD binder and shares it with medical records. Medical Records, who was responsible to get the form signed by the physician. SS stated the form was not complete until the physician signs it. In an interview on [DATE] at 11:02 a.m. with MR, she stated that she scans the DNR form sand emails them to the physician to get it signed. She stated that she tries to get it signed within 24 hours. She stated if the resident was a new admit, she would not leave without uploading the form and sending it to the physician. MR stated she will then take the form to social services, and she puts it in the binder. She stated the DNR form was not complete until the physician signs. MR stated that it was important for the physician to sign the DNR form because if staff does not know that they were DNR and they do CPR, the family would be upset. She verified that the DNR form for Resident #262 was missing the physician signature. She checked her email and did not find anything. MR stated that she was out on [DATE] and the social worker put it in the binder, uploaded it and sent it out to the physician. MR stated she will email the physician right now. In an interview on [DATE] at 11:20 a.m. LVN F, stated that he was Resident #262's nurse. He stated that he could not remember at the top of his head what her code status was, but he would check in PCC. He located Resident #262's in PCC and stated that she was a DNR. He stated that the person responsible for the DNR form to be completed was the social worker. She takes care of asking the families and patients. He stated the DNR form was considered complete when the following signatures were on the form- the patient, the family member, 2 witnesses, and the MD. He stated if the DNR was not signed by the MD that, they can call and get a verbal order. He stated the purpose of the DNR form was to make sure what codes status or whishes the patient chooses in case they code. He stated the DNR code status was located in PCC and in the DNR binder. He stated if the patient does not have a DNR in place, then they were considered a full code. In an interview on [DATE] at 11:30 a.m. with the DON, she stated the DNR form was done upon admission and the social worker also completes the form. The patient and the family will decide if full code or DNR. She stated if the patient was nonverbal then we do full code until the patient's family tells us otherwise. The facility obtains the patient or RP to signature, witnesses and we contact MD. She stated that if DNR form was not signed by MD then it was considered incomplete, but they do honor the patient's wishes since they have the MD order. The DON stated that the MD does not come in daily, and it was impossible to get for signed the same day. She stated that they try to get the MD signature on the DNR form as soon as possible in case the patient goes out to the hospital. If they don't have an MD signature on the DNR form, then the staff will have to call the hospital nurse and inform them that it has not been signed. She stated that there was no timeframe to get the MD signature on the DNR form. She stated that the nurse puts the code status in PCC. The DON stated that as soon as the RP or patient signs form that they change code status in the PCC even if MD has not signed. They get a verbal order; he just hasn't signed the DNR form. Medical records have been told not to take too long to get them signed. The DON provided me with a copy of the DNR at 1:56 p.m., and it revealed the MD signed it today, [DATE]. In an interview on [DATE] at 5:50 p.m. with the ADM, stated that the DNR forms were discussed in their morning meetings. She stated that this was the first thing social services tries to get in motion during new admissions. They also conduct self-audits. She stated that as soon as the DNR forms come in, they get MD signature, or they get a verbal order. They try to have medical records run to their medical office to obtain signatures. She stated that in order for the DNR form to be completed it would have to have all three signatures. ADM stated she was not familiar with the DNR form policy, but social services would be better with the DNR form policy questions. She stated that between medical records and social services, they work on getting MD signatures on the DNR forms. Record review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy dated [DATE], revealed the following: Policy: It is the policy of this facility to support and facilitate a residents right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for heal care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the induvial is incapacitated. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed and advance directive, and if not, determine whether the resident would like to formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart . Record review of the OOH DNR Order instructions for issuing and OOH-DNR Order revealed the Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #40) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #40 was coded in the MDS for a fall on 3/30/25. This failure could place residents at risk of receiving care and services to meet their needs. The findings included: Record review of Resident #40's face sheet dated 05/18/25 reflected Resident #40 was admitted on [DATE] and was [AGE] years old. Resident #40 had diagnoses of muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination, abnormalities of gait (pattern walking or moving on foot) and mobility, dementia (major neurocognitive disorder which causes a progressive decline in cognitive function, such as memory, thinking, reasoning, and judgment), and Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in behavior). Record review of Incident Log reflected Resident #40 had a witnessed fall on 3/30/25. Record review of Resident #40's undated comprehensive care plan reflected: Resident #40 had an actual fall. Educated resident on importance of using call light and waiting for assistance with tall transfers and assistance with ADL on 3/30/35. Labs: UA/C&S on 3/30/25. Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation on 3/30/25. NP/RP/DON notified on 3/30/25. Record review of Resident #40's progress notes dated 3/30/35 at 6:00 pm, written by LVN H indicated a change of condition due to resident stated had a witnessed fall. It also reflected a mental status change, vitals/assessment completed, and notifications made to RP and NP. Labs and medications were ordered. Record review of Resident #40's Discharge MDS dated [DATE] revealed: Section GG130 revealed Resident #40 required partial/moderate assistance for showering/bathing and supervision or touch/setup for all other self-care and Section J1800 and J1900 revealed no falls since Admission/Entry or Reentry or Prior Assessment. In an interview on 5/14/25 at 8:54 am the DON said falls were captured on the care plan by the floor nurse. She said if falls were not captured on the care plan, it could cause a lack of communication with the MDS department. They would not get the information of a resident's fall. She said they also had meetings every day to discuss any incidents, and the MDS department also obtained information on any falls at these meetings. She said the MDS department was responsible for capturing and documenting falls on the MDS assessment. The DON said it would not have any negative outcome on the resident who had a fall, because the floor nurses, ADONs, and DON will edit the care plan upon the fall and add any interventions right away and update as needed. In an interview on 5/14/25 at 3:00 pm MDS G said falls should be captured between MDS assessments. She said for Resident #40, the fall should have been captured on the discharge MDS dated [DATE] and it was not. She said the negative outcomes could be the hospital he was discharged to would not know he had a recent fall and plan interventions for the fall. She said if it had been a fall with a serious injury, they would not know what precautions to take. She said Resident #40 had a no serious injuries from his fall. Record review of CMS's RAI Version 3.0 Manual dated 10/2024, reflected section: J1800: Any falls since admission/entry or reentry or prior to assessment . Coding instructions: Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior to assessment . item (J1900), . J1900: Number of falls since admission/entry or reentry or prior assessment . Coding instructions for J1900A, No Injury: Code 1, one: if the resident had one non-injurious fall since admission/entry or reentry or prior assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #40 and Resident #23) of 8 residents reviewed for care plans, in that: 1.The facility failed to ensure Resident #40's most current undated care plan reflected his diagnosis of dementia. 2.The facility failed to develop a comprehensive person-centered care plan to address Resident #23's antibiotics for pneumonia. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: 1. Record review of Resident #40's face sheet dated 05/18/25 reflected Resident #40 was admitted on [DATE] and was [AGE] years old. Resident #40 had diagnoses of muscle wasting and atrophy (decrease or wasting of tissue, muscle or organs), lack of coordination, abnormalities of gait (pattern walking or moving on foot) and mobility, dementia (major neurocognitive disorder which causes a progressive decline in cognitive function, such as memory, thinking, reasoning, and judgment), and Alzheimer's disease (a type of dementia/neurodegenerative disease that affects the brain causing memory loss, confusion, and changes in behavior). Record review of Resident #40's most recent undated comprehensive care plan did not include dementia as a diagnosis. Record review of Resident #40's quarterly MDS dated [DATE] revealed: Section I - Active Diagnoses Neurological: Non-Alzheimer's Dementia Other: Unsp Dementia, Unsp severity, without beh/psych/mood/anx In an interview on 5/14/25 at 8:54 am the DON said she knew the MDS department had up to 14 days to complete the assessment. She said the MDS department updated the initial care plans from the MDS assessment, such as for dementia, smoking, etc. She said the floor nurses, ADONs, and DON will update care plans as needed for anything new that had not been addressed in the initial care plan, such as upon a fall. The floor nurses would edit the care plan with interventions right away even if there is no injury because an intervention needs to be done. She said if not on the care plan, there would be a lack of communication and interventions not done. In an interview on 5/14/25 at 3:00 pm MDS G said she was the MDS for the facility's long term care residents. She said the comprehensive care plan will be completed with active diagnosis that were on the MD note and were being treated/provided interventions. She said they usually must care plan for a diagnosis such as Dementia, unless it was not an active diagnosis - not receiving any treatments/interventions for the past 30 to 60 days and the MD did not list the diagnosis as an active diagnosis prior to the most recent MDS Assessment. She said there were no specific diagnosis that were automatically care planned. She said they would capture the active diagnosis on the MDS under active diagnosis. She said for Resident #40, the MD did not include dementia in the most recent progress notes dated 5/13/25. Surveyor asked MDS, since the most recent MDS dated [DATE] show Dementia as an active diagnosis, should dementia have been care planned at that time? MDS said dementia was only included on the MDS because as best practice, we were instructed to place all hospital discharge diagnosis on the MDS assessments. She said Resident #40 was only here for wound care and antibiotics and had a BIMS of 14, so dementia should not have been care planned as an active diagnosis. She said there was no MD support for Dementia as an active diagnosis. She said it could be looked as an oversight on the MDS department, but when they complete the next review in 60 to 90 days, they will get with the MD/NP to see which diagnosis were considered active and which could be resolved/removed. She said there would be no negative outcomes because the resident was still receiving care/interventions for his active diagnosis and his BIMS was high. She said Resident #40's MD also made frequent rounds and picked up changes right away. Record review of CMS's RAI Version 3.0 Manual dated 10/2024, reflected section: I: Active Diagnoses in the last 7 days Active Diagnoses in the last 7 days - Check all that apply . Item Rationale Health-related Quality of Life Planning for Care This section identifies active diseases and infections that drive the current plan of care. Steps for Assessment . 2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. 2.Review of Resident #23's admission Record dated 05/12/2025 revealed an admission date of 2/12/2023 and originally admitted on [DATE]. The Resident's diagnoses included Pneumonia (a serious lung infection where the air sacs (alveoli) fill with fluid or pus, causing inflammation and difficulty breathing.), Alzheimer's disease (a progressive, neurodegenerative brain disorder that primarily affects memory and thinking skills). Review of the Resident #23's Care Plan, dated 02/13/2023, revealed the care plan did not identify the resident's treatment for pneumonia. Review of Resident #23's most recent comprehensive MDS assessment dated [DATE], revealed the resident was taking an antibiotic for the last 7 days. Review of the Resident #23's physician orders dated 05/12/2025 revealed Resident #23 received Ceftriaxone sodium intravenous solution reconstituted 1 gram, administer 1 gram via intravenously one time a day for pneumonia for 5 days with a start day on 5/9/2025 and end date 5/14/2025. During an interview on 05/5/25 at 9:44 a.m. MDS G nurse stated the care plan should have been updated when and by whomever received the order for the antibiotic. MDS nurse stated if the care plan was not updated it could affect the nurses by not being able to give the care that Resident #23 needed. During an interview on 5/13/25 at 10:00 a.m. ADON C stated nurses and ADONs were responsible to update the care plan for Resident #23. ADON C stated care plan had to be updated as soon as possible when the order for the antibiotic was received. ADON C stated Resident #23 was at risk of not receiving the care that he needed. ADON said that they monitor any new orders during the morning meetings. During an interview on 05/13/25 at 4:27 p.m. the DON stated the care plan had to be updated to give the resident the best care and to verify if the interventions were effective. The DON stated the care plan had to be updated as soon as possible to give the best care to Resident #23. The DON stated Resident #23 was at risk of not receiving the proper care that he required. Record review of facility's Comprehensive Care Plans policy dated 10/24/22 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed withing 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Seroquel had a proper diagnosis for 1 (Resident #50) of 1 residents reviewed for drug regimen review, in that: The facility failed to address Seroquel (antipsychotic) being given to a resident with diagnosis of dementia. This deficient practice could place residents at risk of receiving unnecessary medications and dosages. The findings were: Record review of Resident #50's face sheet dated 05/13/25 revealed an [AGE] year-old male initially admitted to the facility on [DATE] with the diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a diagnosis of dementia where the type and severity are unknown, and there are no significant psychological or behavioral symptoms like aggressiveness, agitation, or psychosis), Hallucinations (a perception that someone experiences as real, but that has no actual external stimulus). Record review of Resident #12's care plan dated 05/10/21 revealed Resident #50 had impaired cognitive function and impaired processes related to lewy body dementia(a progressive neurodegenerative disorder characterized by the buildup of abnormal protein clumps called lewy bodies in the brain), black box warning: elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine (Seroquel) is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #50's MDS dated [DATE] revealed he had a BIMS score of 12, indicating he had moderate cognitive impairment. Resident #50's MDS section N-Medications, he had received antipsychotics on a routine basis only. Record review of Resident #50's Order Summary Report, dated 05/13/25 revealed, Seroquel Tablet 100 MG (Quetiapine Fumarate) Give 4 tablet by mouth two times a day related to lewy body dementia with behavioral disturbance. Start date of 1/10/25. During an interview on 5/13/25 at 10:50 a.m. LVN B stated Seroquel was an antipsychotic medication given for anxiety or insomnia. LVN B stated if an antipsychotic medication was given to a resident with dementia, Resident #50 could be drowsy. LVN B stated dementia was not a diagnosis for an antipsychotic medication. During an interview on 5/13/25 at 1:30 p.m. LVN E stated that she knew that lewy body dementia was not an appropriate diagnosis for an antipsychotic and that she called the Veterans office to clarify and was told that lewy body dementia was an appropriate diagnosis for the Seroquel. LVN E stated that a negative outcome could be resident declining, increase fall risk, and the resident could worsen his medical condition. LVN E stated that resident did not have any side effect to this medication. During an interview on 5/13/25 at 12:10 p.m. ADON C stated Seroquel was an antipsychotic used for depression. ADON C stated lewy body dementia was not an appropriate diagnosis for Seroquel because it could cause the opposite effect on the patient, increase lethargy, or an adverse reaction. ADON C stated that resident did not have any side effect to this medication. During an interview on 5/13/25 at 4:00 p.m. DON stated Physicians were the ones who orders antipsychotics and gave the diagnosis. The DON stated the negative outcome of giving a resident who has the diagnosis of dementia or Alzheimer's an antipsychotic for dementia or Alzheimer's could be adverse side effects. DON stated that resident did not have any side effect to this medication. DON said that the physician was called and stated that this diagnosis was for this medication. Record review of facility's policy on Use psychotropic Medication (s) dated 3/5/25 (implemented date 3/5/25), revealed: Policy Statement: it is the intent f this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (200 hallway cart) of 4 medication carts. The facility failed to ensure expired supplies and medications were removed from the nurses' medication cart for 200 hall. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on 05/13/2025 at 02:48 PM of the 200 hall nurse's medication cart with LVN A revealed 1 box of famotidine 10milligrams with an expiration date of 4/2025. During an interview on 5/13/25 at 8:00 a.m. LVN A stated all of the nurses were responsible for checking for expiration dates on the medications and supplies in the medication carts. LVN A stated using the expired medications and supplies could lead to the medications and topical treatments not being as effective. During an interview on 5/13/25 at 12:10 p.m. ADON C stated taking the medication past the expirations date could lead to decreased effectiveness or ad verse effects including sickness. ADON C stated that nurses were responsible for checking the medication cart. During an interview on 5/13/25 at 4:45 p.m. the DON stated nurses, were responsible for ensuring expired medications were pulled from the medication carts. The DON stated that the negative outcome could be the medication was not as potent and resident would not receive the full benefit of the medication. The DON said that inservices were done quarterly on expired medications. DON said that she did routine rounds and checking the medication carts. Record review of facility policy Medication Administration dated 10/24/22 revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Identify expiration date. If expired, notify nurse manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 facility in that: The facility failed to have pest control effectively treat the facility for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings include: During an observation on 05/13/2025 at 4:38 p.m., revealed a live roach on the floor in the hallway of the 400 hall. This observation was pointed out to LVN I, who immediately stepped on it, and walked away. Housekeeping staff swept the roach up. CNA J was charting in the hallway where the live roach came out. During an interview on 05/13/2025 at 4:40 p.m., CNA J stated that she has not seen roaches in the facility until now. She has not seen pest control, but she has heard that they do come in. During an interview on 05/13/2025 at 4:45 p.m., LVN I stated that she has not seen roaches in the facility that often. She stated that they have a pest control sighting logbook in place at the nurse's station where they were to document if they see any ants or roaches. Maintenance staff will take care of contacting pest control. Housekeeping staff takes care of cleaning up the pests. LVN I stated she has seen pest control come in. She stated the roaches can create all kinds of infections to the residents and the roaches can get on the resident's food. During an interview on 05/13/2025 at 4:50 p.m., Maint Dir stated that he was already informed of the live roach. He stated that pest control comes every month. They have a pest control sighting logbook at the nurse's station for the staff to document whenever they have a sighting of any bugs. He stated that housekeeping will go out and deep clean the room of where the bug was seen. Pest control would then be provided with a list of all sightings, and they spray accordingly. He stated the 400-hall nurse notified him and the housekeeping supervisor. The Maint Dir stated the negative outcome was that the roaches can get on the resident's food, belongings or on them. During an interview on 05/13/2025 at 4:57 p.m., Env Supv stated that sometimes they do have roaches but was rare. The staff notifies her if they see roaches or any other bugs. She will go see the room and put it on the pest control sighting logbook at the nurse's station. Maintenance will take care of it with the pesticide company. Her staff will go and deep clean the room. She stated pest control come out once a month. The Env Supv stated having a roach free facility was best for patient safety and to have a clean environment. During an interview on 05/13/2025 at 5:12 p.m., ADM, stated they have a pest control vendor entering the facility monthly and as needed. She stated that the roaches go with the weather when wet and they had recent flooding. The staff do rounds every morning to check the environment and would report any concerns they found. If there were any concerns, we do a deep clean in that room. She stated staff documents it in the pest control sighting logbook. They then discuss it in the morning meetings, and it gets entered into TELS. TELS sends maintenance a work order. ADM stated roaches in the facility were nasty, they could get in the resident's wounds and in their beds. She stated that they do not have a pest control policy. Record review of Pest Control sighting logbook revealed two entries for the month of April 2025- dated 04/01/2025 noted roaches in front of the restroom [ROOM NUMBER] and 04/21/2025 note live small roach at end of 200 hall. There was one entry for the month of May 2025, dated 05/12/2025 noted small roaches in bathroom. Record review of Pest Control Invoice, dated 04/25/2025, revealed the following services, Regular Pest Service and Flying Insect Program. Under General Comments/Instructions: Talked to contact, look over sighting log and inspected and treated rooms [ROOM NUMBER] for Roaches. Interior . Inspected and treated kitchen, dining, laundry, offices, employees area, hallways, bathrooms, and nurses station checked and changed glue boards as well. Exterior .Inspected and treated perimeter of building and replaced baits in rodent bait stations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report an allegation of physical resident abuse by CNA B and CNA C of Resident #1 during a bed bath. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1's admission Record dated 03/31/25, revealed a [AGE] year-old female, originally admitted to facility on 11/03/19. Resident #1's diagnoses included: Dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic kidney disease (a condition characterized by a gradual decline in kidney function over a period of at least three months), atherosclerotic heart disease (a buildup of fats, cholesterol, and other substances in and on the artery walls causing obstruction of blood flow), hypertension (high blood pressure), encounter for palliative care (a specialized form of medical care that focuses on improving the quality of life for people with serious or life-limiting illnesses). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Record review of Hospice Complaint Report dated 03/12/25 at 12:00 PM, revealed on 03/12/25 at 11:30 AM Hospice CNA A notified RNHA D of the following: Hospice CNA A REQUESTED ASSISTANCE WITH THE PATIENTS BATH FROM THE FACILITY NURSE AIDES AS THE PATIENT'S HAIR AND HANDS CONTAINED FECES. SHE REPORTS TWO NURE AIDES CAME INTO THE PATIENT'S ROOM TO ASSIST HER. SAN [NAME] REPORTED THE FOLLOWING: THE NURSE AIDES IN A 'HARSH WAY TOOK OVER THE BED BATH ONE ON EACH SIDE OFTHE BED ONE WAS HOLDING HER HANDS WHILE THE OTHER ONE WAS POURING WATER ON HER HEAD WITH HER HANDS Resident #1 WAS VERY UPSET I TOLD THEM TO STOP THAT I WOULD DO IT MYSELF THEY MOVED AND I TOOK OVER SHE WAS UPSET AND THIS HAPPENED ON MONDAY I REPORTED THIS TODAY TO THE HALL NURSE [NAME] AND SHE WENT AND REPORTED TO ADON AND ADMINISTRATOR.' Hospice CNA A STATES THIS OCCURRED ON 3/10/25; INCIDENT WAS REPORTED ON 3/12/25 AT ABOUT 11:30 AM. Report goes on, RNHA D wrote, CALL PLACE TO ADMINISTRATOR AT NURSING FACILITY. RNHA D INFORMED Administrator ABOUT THE REPORT RNHA D HAD RECEIVED FROM OUR HOSPICE AIDE. AS PER NF Administrator, THEY WERE AWARE OF THE REPORT. SHE STATES THE FACILITY ADON CONDUCTED A PATIENT ASSESSMENT OF THE PATIENT. NF Administrator STATES SHE ASKED THE PATIENT ABOUT THE OCCURENCE AND IN ADDITION ASKED THE PATIENT IF SHE FELT SAFE. PER NF Administrator, THE PATIENT STATED SHE FELT SAFE AND NO OTHER CONCERNS WERE NOTED DURING HER INVESTIGATION. NF Administrator STATES SHE HAS AN UPCOMING INSERVICE FOR HER STAFF OF TIMELY REPORTING OF ANY SUSPECTED ABUSE OR NEGLECT AND THAT SHE WILL REINFORCE ZERO TOLERANCE OF ANY SORT. PER NF Administrator, HER INVESTIGATION DID NOT RESULT IN SIGNED OF MISTREATING OF THE PATIENT. Hospice STAFF VISITS FOR THE PATIENT ON 3/12/25. NO CONCERNS WERE REPORTED AFTER COMPLETION OF VISITS. Record review of Resident #1's Care Plan dated 03/19/25 revealed: FOCUS: o Resident #1 has episodes of smearing her feces/playing with feces Date Initiated: 01/21/2025 GOAL: o The resident will have fewer episodes through lookback period Date Initiated: 01/21/2025 Target Date: 06/17/2025 INTERVENTIONS/TASKS: o Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 01/21/2025 LN o Encourage and assist resident to clean hands/nails after episodes and PRN Date Initiated: 01/21/2025 Revision on: 01/30/2025 CMA LN o Notify MD if episodes increase or of changes in condition Date Initiated: 01/21/2025 LN o Provide incontinent care routinely and PRN Date Initiated: 01/21/2025 CNA LN o Redirect and reassure resident as needed/when possible Date Initiated: 01/21/2025 Revision on: 01/21/2025 CNA LN In an interview on 03/26/25 at 11:25 AM RNHA D stated, Hospice CNA A had told her about the alleged abuse of Resident #1, a resident at NF. RNHA D stated they did their investigation with their (Hospice) Social Worker and nurse. RNHA D stated she did follow-up with the NF facility administrator, who said the facility did their own investigation and did not find any abuse. In an interview on 03/26/25 at 04:16 PM CNA A stated she was a CNA for hospice. CNA A stated she went to the facility to take care of her patient, Resident #1, on that Monday (03/10/25). CNA A stated on 03/10/25, Resident #1 was covered in BM when she went in. CNA A said BM was even under Resident #1's fingernails. CNA A stated she wanted to give Resident #1 a bed bath and asked two CNAs from the facility to help because Resident #1 was handsy and always trying to touch her. CNA A stated the facility CNAs took over the bed bath. CNA A stated she felt like they were being a little rough with Resident #1. CNA A stated they seemed angry at having to help her. CNA A stated the one CNA (CNA B) was putting water over Resident #1's head and the other CNA (CNA A did not know her name) was attempting to hold her hands while Resident #1 was telling them to leave her alone. CNA A was upset with the two CNAs for the way they were being to Resident #1 and taking over, CNA A stated she told the two CNAs that she would finish the bed bath and the two CNAs left the room. CNA A stated she did not think Resident #1 liked those two CNAs just by the way she was acting with them. CNA A stated she did not tell the nurse on the hall of the two CNAs roughness until Wednesday, 03/12/25, when she went to take care of Resident #1 again. In an interview on 03/31/25 at 11:06 AM, Resident #1 stated, the one woman from the place who comes to give me baths is very good and very nice. Two of the ones here do not like me. Those two do not like me. They (CNAs) have ones they like and me, they don't like. Resident #1 stated she did not want to tell surveyor the names of the two who did not like her. In an interview on 03/31/25 at 01:05 PM the administrator stated they did not have to report allegation of abuse from the Hospice CNA because they investigated and unsubstantiated the findings. The administrator stated the Hospice CNA did not report the allegation until days later. She said she spoke with the hospice administrator and she was aware of the facility's findings. In an interview on 03/31/25 at 02:30 PM CNA B stated she had worked at the facility for 3 years in April. CNA B stated she gave showers to the residents. CNA B stated when the Hospice CNAs ask for help, they would help them with their bed baths and showers. CNA B stated if once in the shower/bed bath, the resident changed their mind and told you to leave them alone, CNA B stated they would stop the bed bath or shower right away and change the resident, so they are comfortable. CNA B stated if there was soap on the resident, they would tell the resident they were rinsing the soap and would finish after that. CNA B stated they notify the nurse the resident did not want a bed bath or shower. CNA B stated if the resident were grabbing at you, pinching you, trying to hit you, she would try to calm them and would tell them to relax. CNA B stated she would tell the nurse the resident had been aggressive. CNA B stated she would not hold their hands so they could not hit or pinch because she could cause a skin tear if she did. CNA B stated they had skill check offs on bed baths/showers. CNA B stated every year they had a check off around August. CNA B stated she probably did give showers on 03/10/25. CNA B stated she helped the hospice CNA change sheets one day, but she has not helped give a bed bath. CNA B stated if the Hospice CNA needed assistance for a bed bath, the Hospice CNA could ask either one of them. In an interview on 03/31/25 at 02:35 PM CNA C said she had been working at the facility for one year. CNA C stated she gave showers. CNA C stated when the Hospice CNA asks for help they would help with bed baths and showers. CNA stated if once in the shower/bed bath, the resident changed their mind and told her to leave them alone, she would try to convince the resident to let her finish the bath and if she could not, she would terminate the shower/bed bath. CNA C stated if the resident was grabbing at her, pinching her, trying to hit her, she would try to calm them. CNA stated she would tell the nurse the resident had been aggressive. CNA C stated she would not hold the resident's hands to prevent them from hitting her. CNA C stated the CNAs were given skills check off every year. CNA C stated she and CNA B went in to help the Hospice CNA with a bed bath that day (03/10/25). CNA C stated Resident #1 refused the bed bath and the Hospice CNA said she would finish. In an interview on 03/31/25 at 05:48 PM the DON stated neither Resident #1 or CNA B or CNA C had ever alleged abuse to her. In an interview on 03/31/25 at 06:15 PM the administrator stated neither Resident #1, the nurses nor the CNAs have alleged abuse to her concerning Resident #1. Review of facility's Abuse, Neglect, Exploitation Policy dated 08/15/22, revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting / Response A. The facility will have written procedure that include: 1.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 6 Residents (Resident #2) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1. CNA E failed to don the appropriate PPE before she entered Resident #2's room. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: 1. Record review of Resident #2's face sheet, dated 03/31/25, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Heart failure, type 2 diabetes mellitus (high levels of sugar in blood), ESBL to urine (type of antibiotic resistance gene found in bacteria that can produce enzymes that break down certain antibiotics, including penicillins, and cephalosporins. Record review of Resident #2's Minimum Data Set assessment, dated 02/24/25, revealed Resident #2 had a BIMS score of 12, indicating he was cognitively intact. Record review of Resident #2's physician's orders, retrieved on 03/31/25, revealed orders for Contact isolation DX: ESBL/URINE every shift for UTI ESBL until 04/02/25 2359 (11:59 PM) with a start date of 03/25/25. Observation of Resident #2's signage posted on the outside of Resident #2's door on 03/31/25 at 11:25 AM revealed Resident #2 was on contact precautions. CNA E entered Resident #2's room moved Resident #2 while he was sitting in his wheelchair and moved the bedside table to in front of Resident #2 readying him for lunch, without donning gown or gloves. Interview on 03/31/25 at 11:28 AM CNA E came out of Resident #2's room and was asked why she did not have on a gown and gloves. CNA E pointed to Contact Precautions sign and stated she did not have contact with the resident so she did not have to put on a gown or gloves. In an interview on 03/31/25 at 11:30 AM LVN F stated the Contact Precautions signage meant that if the CNA were changing a resident or having direct contact, the CNA would need to put on a gown and gloves. LVN F stated Resident #2 had ESBL to urine. LVN F stated the negative outcome of going into a room on contact precautions could be whoever entered without using PPE could spread the infection or catch the infection. In an interview on 03/31/25 at 11:34 AM CNA E stated by entering a room on Contact Precautions and not putting on a gown and gloves, she could get the infection or spread the infection. In an interview on 03/31/25 at 11:35 AM CNA G stated when there is a Contact Precautions sign on a resident's door, everyone every time must put on PPE before entering the room. CNA G stated if PPE were not put on, the infection could spread. In an interview on 03/31/25 at 04:30 PM LVN ADON H stated when there was Contact Precautions signage, the resident had an infection. PPE was to be put on outside and then go in the room. LVN ADON H stated every time they would go in the room they put on PPE. LVN ADON H stated if PPE is not worn and infection control is not observed, cross contamination can occur. LVN ADON stated the Enhanced Barrier signage was for when they put on PPE for wounds, midlines, foley or colostomy with resident contact for infection control. LVN ADON H stated Infection Control in-services are on-going all the time. LVN ADON H stated the other ADON had the in-servicing for Infection Control. 03/31/25 05:48 DON stated Contact Precautions signage was put on a resident's door when the resident had an infection. The DON stated everyone puts on their PPE outside and then they go in the room. The DON stated every time they go in the room they put on PPE. The DON stated if PPE was not worn and infection control was not observed, spread of the infection and cross contamination could occur. The DON stated Enhanced Barrier signage. DON stated Enhanced Barrier precautions was to prevent infection. She stated PPE was worn for wounds, midlines, foley or colostomy with contact for infection control. The DON stated Infection Control in-service are weekly or every other week or at least several times a month. The DON stated the ADON gave the in-servicing for Infection Control and she helps. Record review of facility policy titled, Infection Prevention and Control Program with an implemented date of 05/13/23, revealed: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. c. All staff shall use personal protective equipment (PPE)according to established facility policy governing the use of PPE. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 2 (Resident #23 and Resident #61) of 11 residents whose records were reviewed for Out-of-Hospital Do-Not-Resuscitate Order forms in that:resident rights. The Facility did not ensure Resident #23 nor Resident #61's OOH-DNR form was completed fully and correctly. This failure could place residents at risk of not having their code status wishes met in the event they were needed. The findings included: 1.Record review of Resident #23's face sheet with an admission date of [DATE] reflected he was an [AGE] year-old male with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes, and hypertension. Record review of Resident 23's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 which indicated Resident #23 was cognitive intact. Record review of Resident #23's Comprehensive Care Plan dated [DATE] reflected: Focus: Resident #23 is a DNR dated [DATE] Goal: Facility will comply with resident/family wishes Date Initiated: [DATE] Target Date: [DATE] Interventions/Task: If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification Date Initiated: [DATE] -Keep resident as comfortable as possible at all times Date Initiated [DATE] -Social services consult if resident/family want to change code status Date Initiated: [DATE]. Record review of Resident #23's OOH-DNR form dated [DATE] reflected no physician signature under Physician's Statement. 2. Record review of Resident #61's admission Record dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the diagnoses which included cerebral infarction (stroke), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypertension (high blood pressure), and gastrostomy status (placement of a feeding tube through the skin and the stomach wall). Record review of Resident #61's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 11 which indicated Resident #61 had moderate cognitive impairment. Record review of Resident #61's Care Plan dated [DATE] reflected: FOCUS: o Resident is a DNR Date Initiated: [DATE] GOAL: o Facility will comply with resident/family wishes Date Initiated: [DATE] Target Date: [DATE] INTERVENTIONS/TASKS: o If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification Date Initiated: [DATE] LN o Keep resident as comfortable as possible at all times Date Initiated: [DATE] LN o Social services consult if resident/family want to change code status Date Initiated: [DATE] Social services Record review of Resident #61's Physician's Orders reflected an active order dated [DATE] for a code status of DNR (Do Not Resuscitate). Record review of Resident #61's OOH-DNR form dated [DATE] reflected no physician signature under Physician's Statement. In an interview on [DATE] at 02:26 p.m., MDS LVN T stated the social worker oversaw obtaining DNR forms. MDS LVN T stated once the DNR form had the resident/RP and witness signature, the social worker would let MDS know, and they would update the resident's medical record to reflect their DNR status. MDS LVN T stated if the DNR form had been uploaded, signed by resident/RP and witnesses, it was considered a valid form. She stated if a resident coded, the nurse would check PCC face sheet and under miscellaneous to make sure the resident/RP and witnesses signed the DNR. She said she was not sure if the nurses would check for the physician's signature. MDS LVN T stated the social worker would also inform medical records of a resident's DNR status and they would assist in obtaining physician's signature. In an interview on [DATE] at 02:40 p.m., MR Q stated when a resident was a DNR, the social worker was responsible for obtaining the DNR form. She stated once the resident/RP and witnesses signed the DNR form, she would inform MDS so they could update resident's records. MR Q said the social worker would place the DNR form in a binder that was kept in the nurse's station to make it readily available for the physician. MR Q said the social worker would inform medical records so they could also assist in obtaining the physician's signature. MR Q said she usually gave the physician 72 hours to sign the DNR form and if they did not sign within that time, she would contact them. She said there had been times in which she had to meet the physician outside the facility to acquire their signature. MR Q said when a resident codes, the nurses would check PCC under face sheet and under miscellaneous. MR Q stated as long as the DNR form had been uploaded, signed by resident/RP and witnesses, they will honor the resident's DNR status. In an interview on [DATE] at 11:22 a.m., SW U (from sister facility) said the facility's social worker, who was on vacation, was responsible for obtaining the DNR form. She stated the social worker would discuss advanced directives with resident/RP upon admission and upon their request thereafter. SW U said she would explain the process and if they wanted to pursue a DNR status, she would obtain the resident/RP signature and 2 witnesses. SW U said after the resident/RP and witnesses' signatures were obtained, she would notify the charge nurse for a change of code status. SW U said the charge nurse would contact the physician and obtain a verbal order. SW U stated after that, she would give the DNR form to medical records for them to have it ready for the physician to sign. SW U stated she did not know how much time a physician was given to sign the DNR form but said she would try to obtain the physician's signature within 72 hours. SW U stated if a resident codes, nursing staff would check PCC's face sheet and under miscellaneous to see if the DNR form had been signed by resident/RP and witnesses, and if it had, they would honor the DNR status and the DNR form would be considered a valid form even if it did not have a physician's signature. In an interview on [DATE] at 03:00 p.m., ADON RN E said when a resident coded, the nurse would check PCC's face sheet and under miscellaneous for the DNR. ADON RN E stated the nurse should know not to rely solely on PCC, they also needed to check the binder by the nurse's station to make sure the resident's DNR form had all required signatures. ADON RN E said all DNR forms that were in the binder by the nurse's station should have a physician's signature. She said the SW was responsible for maintaining the binder up to date. ADON RN E said medical records also assist in obtaining the physician's signature, but ultimately it was the SW's responsibility. ADON RN E said the SW wouldill give the physician 3 days to come in and sign the DNR form, if it were not signed within 3 days, the SW and medical records would start calling the physician to remind them their signature was needed. ADON RN E said if a resident coded and the DNR form was not signed by the physician, it would not be honored. ADON RN E said the nurse will call their family to see what they say. ADON RN E said if they could not get a hold of family, their DNR status would not be honored. On [DATE] at 05:10 p.m., the Administrator and Clinical Resources Nurse stated they did not have a policy concerning DNRs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 residents ( Resident #49) of 4 residents reviewed. The facility failed to report within 24 hours, the allegations of resident abuse to the State Survey Agency for Resident #49. This failure could place all residents at increased risk for potential abuse and neglect due to unreported allegations of abuse and neglect. The findings included: Record review of Resident # 49's face sheet dated 03/14/2024 with an admission of 02/21/2018 and an initial admission date of 02/05/2017 reflected she was an [AGE] year-old female with diagnoses of Alzheimer's disease, dementia, major depressive order, anxiety, and bipolar. Record review of Resident #49's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 03 which indicated impaired cognition. Record review of Resident #1's face sheet dated 03/14/2024 with an admission date of 07/29/22 and an original admission date of 08/11/2020 and a discharge date of 12/06/23 reflected he was a [AGE] year-old male with diagnoses of congestive heart failure, chronic kidney disease, and dementia. Record review of Resident #1's quarterly MDS assessment reflected he had a BIMS score of 07 which indicated he was moderately impaired cognition. Record review of Resident #49's Provider Investigation Report reflected on 08/24/2023 at 10:30 a.m., Resident #1 and Resident #49 were sitting in their wheelchair next to each other on the 200 hall. Staff observed Resident #1 rubbing his hand over Resident #49's breast area over the top of her clothing. Staff separated Resident #1 from Resident #49. Resident #1 was later moved to another hall. RP and PCP were notified. Facility did not report the incident because no allegations were made. On 08/25/2023 at about 4:00 p.m., Resident #49's RP called the facility and asked for the incident to be reported to the authorities as Resident #1's actions were not appropriate. Local police department was notified at 4:30 p.m. The investigation findings were unconfirmed for abuse. Record review of Incident Worksheet reflected the facility reported the incident on 08/25/2024 at 6:14 p.m. During an observation on 03/14/2024 at 10:25 a.m., Resident #49 was observed in her wheelchair in the dining room. She was well groomed and dressed in her own clothing. An attempted interview on 03/14/2024 at 10:30 a.m., Resident #49 was not interviewable. An interview on 03/14/2024 at 11:34 a.m., the Administrator/Abuse Coordinator said the incident between Resident #1 and Resident #49's was an interesting situation. He said when it was reported to him, the first impression was Resident #1 was the aggressor, but as they talked about it was determined Resident #49 was very friendly and invited human contact. The Administrator said there was no outcry from Resident #49. The Administrator said he called Resident #49's RP the next day (08/25/2023) and she got upset saying Resident #1 was a predator and that Resident #49 had been abused. The Administrator said, Resident #1 was immediately changed to another hall, they placed a blue flag on his wheelchair to help staff locate him at all times. The Administrator said Resident #1 had no history of inappropriate behavior or touching other residents. He said Resident #1 was transferred to another facility at family's request on 12/06/2023. The Administrator said he was familiar with the timeline of reporting incidents to state office and was not sure why he had not reported the incident Resident #49 timely. The Administrator did not say what the risks of not reporting incidents to state office in a timely manner were. Record review of facility's Abuse, Neglect and Exploitation policy dated 08/15/22 reflected: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment when resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, in respected are there any mental or physical condition, cause physical harm, he or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse: There's non-consensual sexual contact of any type with a resident. Neglect: Means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement with applicable) within specific timeframes: a. Immediately, but not later than 2 hours after the allegation is made I f the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 4 residents (Resident #268) reviewed for care plans, in that: The facility failed to address, in Resident #268 baseline care plan, her feeding assistance upon admission. This failure could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care. The findings included: Record review of Resident #268's face sheet with an admission date of 03/09/2024 reflected she was a [AGE] year-old female with diagnoses of severe protein-calorie malnutrition (is a severe form of malnutrition), kyphosis (an abnormality of the spine causing excessive curvature of the upper back causing pain and stiffness), and adult failure to thrive ( a decline in health and functional abilities, often accompanied by weight loss, muscle wasting, fatigue and decreased quality of life. It can affect appetite, social activities, memory, and daily functions). Record review of Resident #268's baseline care plan dated 03/09/2024 reflected: 2. Eating: set up or clean-up assistance Record review of Resident #268's hospital order dated 03/05/2024 by OT indicated her current ADL was a maximum assist for eating assistance. Record review of Resident #268's hospital's order with a start date of 03/09/2024 with no end date called for a regular diet, pureed texture, regular liquids consistency. Record review of Resident #268's daily skilled noted dated 03/09/2024 at 6:23 p.m. authored by LVN N reflected eating: setup or clean up assistance. Record review of Resident #268's occupational therapy evaluation and plan of treatment dated 03/10/2024 reflected: Diagnoses: need for assistance with personal care. Functional skills assessment-activities of daily living and instrumental ADL's: Self feeding-total dependence without attempts to initiate. An observation on 03/11/24 2:40 p.m., Resident # 268 was observed lying in bed, Resident #268 had pillows under her left and right arms and on her upper back. She was leaning/slouching forward towards her left side. Her head was dropped all the way to her upper chest. She was observed trying to hold her head up with her left hand but when she would put her hand down her head would drop. Resident #268 was observed being thin and frail. During an interview on 03/11/24 at 2:45 p.m., Resident #268 had difficulty speaking but managed to ask where she was. Resident #268 was not able to answer any questions related to her care An observation on 03/12/24 at 12:30 p.m., revealed Resident #268 was observed awake and sitting in a 45-degree angle and leaning/slouching to her left side. She had her food plate in front of her but was not eating. There were no CNA's assisting her. During an observation/interview on 03-12-24 at 1:30 p.m., CNA J was observed walking out of Resident #268's room with a meal tray. Surveyor asked CNA J who that tray belonged to, and she answered it belonged to Resident #268. CNA J removed the lid from the plate, and it was observed Resident #268 had not eaten anything. CNA J said Resident #268 only required supervision/encourage and did not require assistance with eating. CNA J said CNA's were responsible to inform the charge nurse when a resident does not eat 100 % of their meals. An interview on 03-12-24 at 1:32 p.m., Resident #268 said she was hungry and thirsty, she stated someone had taken her lunch tray away. Resident #268 said no one assisted in feeding her. An observation on 03-12-2024 1:40 p.m. COTA Q repositioned Resident #268. Resident #268 voiced to COTA Q that she was hungry and thirsty. Resident #268 pointed to the water cup on her bedside table and asked COTA Q to give her water, COTA Q told her she had to ask her nurse first. COTA Q walked out of room. An observation on 03-12-24 at 1: 45 p.m., COTA Q came back to Resident #268's room to tell her she had advised her nurse she was hungry and thirsty. COTA Q told Resident #268 her nurse had ordered her something to eat and drink and walked out of room. An observation on 03-24-24 at 2:03 p.m., dietary aide walked into Resident #268's room with a tray of oatmeal, milk, and water. At the same time, the dietary aide walked in, the Rehab Director walked in with CNA J and closed the door. An interview on 03-12-24 at 1:50 p.m., LVN N said when a new resident is admitted his/her charge nurse was responsible for the initial evaluation. She said during the initial assessment, the resident would be asked questions to determine the amount of assistance needed with their activities of daily living which include eating. She said they would ask the resident can you eat by yourself or need assistance. LVN N said if the resident is non-interviewable, they will follow the hospital recommendations until an OT evaluation is done. An interview on 03-13-2024 at 9:17 a.m., Rehab Director said when a new resident was admitted , and had an order for a therapy evaluation (occupational/speech/physical) they have between 1 to 3 days to be evaluated. The Rehab Director said if the resident is admitted on a Saturday they will be evaluated on Sunday. The Rehab Director said Resident #268 had been evaluated by an occupational and speech therapy on 03/10/2024. An interview on 03/13/2024 at 11:15 a.m., OT S said she conducted an occupational assessment on Resident #268 on 03/10/2024. She said the assessment consisted of testing her ability to eat. OT S said Resident #268 was kyphotic and did not have the posture to feed herself. OT S said Resident #268 did not have the ability to look up at the table to see what was on it because she was not able to hold her head up. OT S said she and a cna sat Resident #268 on the side of the bed and her head was hanging. She said Resident #268 was too weak she was falling backwards and was not able to hold her position. OT S said she assessed her as a total dependence for all ADL's. OT S said Resident #268's cognition and mobility was poor. OT S said when she was done with Resident #268's assessment she told the charge nurse of her findings (she did not remember the name of the nurse). An interview on 03/13/2024 at 5:17 p.m., LVN O said she was the charge nurse on 03/09/2024 for the 2 pm to 10 pm shift. LVN O said when Resident #268 arrived from the hospital between 3:00-4:00 p.m., said she went to Resident #268's room to welcome and assess her. LVN O said Resident #268 told her she was hungry, and she ordered a dinner plate for her. LVN O said she followed the hospital orders for meals. LVN O said she stayed with Resident #268 until her meal tray arrived. LVN O said when her meal tray arrived, she sat her up and prepared the tray. LVN O said she witnessed Resident #268 trying to grab the utensils and managed to put some food in her mouth. LVN O said because she had witnessed Resident #268 trying to eat on her own, she verbally instructed the CNA's to supervise her meals. LVN O said by supervised meals she meant CNA's were to encourage the resident to eat and to inform the charge nurse of the percentage she ate. LVN O said she documented Resident #268's assessment on her progress notes under daily skilled note. An interview on 03/13/2024 at 5:30 p.m., ADON RN E said Resident #268 was admitted on [DATE]. She said when new residents were admitted on the weekend the facility would follow the orders from the hospital. ADON RN E said the charge nurse would also call the resident's physician to inform them of their admission and if they want the facility to resume the orders from the hospital. ADON RN E said charge nurse was the one responsible for calling the resident's physician as soon as the resident arrives to the facility. ADON RN E said Resident #268's hospital orders reflected she was a maximum assist for eating and LVN O should have instructed the CNA's Resident #268 required assistance in eating. ADON RN E said the charge nurse on the 10 p.m. -6:00 a.m. shift documented on her skilled nurse notes Resident #268 needed assistance with eating. Record review of facility's Baseline Care Plan policy dated 10/22/2022 and revised on 10/05/2023 reflected: Policy: The facility will develop and implement a baseline care plan for each resident that included the instruction needed to provide effective and person-centered care of the resident and meet professional standard of quality of care: 1. The baseline care plan will: b. Include the minimum healthcare information necessary to properly care for a resident including, but limited to: iii. Dietary orders 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident or resident representative, if applicable. b. Interventions shall be initiated that address the resident's current needs including: ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition for 1 of 4 (Resident #268) residents reviewed for ADL care. The facility failed to ensure Resident #268 received assistance with eating. These failure placed residents at risk of poor nutrition, and weight loss. The findings included: Record review of Resident #268's face sheet with an admission date of 03/09/2024 reflected she was a [AGE] year-old female with diagnoses of severe protein-calorie malnutrition (is a severe form of malnutrition), kyphosis (an abnormality of the spine causing excessive curvature of the upper back causing pain and stiffness), and adult failure to thrive ( a decline in health and functional abilities, often accompanied by weight loss, muscle wasting, fatigue and decreased quality of life. It can affect appetite, social activities, memory, and daily functions). Record review of Resident #268's hospital order dated 03/05/2024 by OT indicated her current ADL was a maximum assist for eating assistance. Record review of Resident #268's hospital's order with a start date of 03/09/2024 with no end date called for a regular diet, pureed texture, regular liquids consistency. Record review of Resident #268's baseline care plan dated 03/09/2024 at 8:58 p.m. reflected: Eating: set up or clean-up assistance Record review of Resident #268's occupational therapy evaluation and plan of treatment dated 03/10/2024 reflected: Diagnoses: need for assistance with personal care. Functional skills assessment-activities of daily living and instrumental ADL's: Self feeding-total dependence without attempts to initiate. Record review of Resident #268's skilled nurses notes dated 03/10/2024 at 07:28 p.m., reflected Resident #268 was dependent for eating. Record review of Resident #268's Dietary Mini Nutritional assessment dated [DATE] at 5:52 p.m., reflected: Screening: had a moderate decrease in food intake, BMI less than 19. Resident #268 scored a 6.0 which indicated she was malnourished. Record review of Resident #268's SBAR dated 03/12/2024 at 1:25 p.m., reflected signs and symptoms of decreased meal intake. Nursing notes: call placed to NP due to resident with decreased meal intake new orders received to get dietary consult. Record review of Resident #268's weight history reflected she was weighed on 03/12/2024 at 3:16 p.m. and was 84 pounds. Record review of Resident #268's Dietician's Nutrition Therapy assessment dated [DATE] at 3:28 p.m., reflected % intake of meals as being poor and a dependent feeding ability. An observation on 03/12/24 at 12:30 p.m., Resident #268 was observed awake and sitting in a 45-degree angle and leaning/slouching to her left side. She had her food plate in front of her but was not eating. There were no CNA's assisting her. During an observation/interview on 03-12-24 at 1:30 p.m., CNA J was observed walking out of Resident #268's room with a meal tray. Surveyor asked CNA J who that tray belonged to, and she answered it belonged to Resident #268. CNA J removed the lid from the plate, and it was observed Resident #268 had not eaten anything. CNA J said Resident #268 only required supervision/encourage and did not require assistance with eating. CNA J said CNA's were responsible to inform the charge nurse when a resident does not eat 100 % of their meals. An interview on 03-12-24 at 1:32 p.m., Resident #268 said she was hungry and thirsty, stated someone had taken her lunch tray away. Resident #268 said no one assisted in feeding her. An observation on 03-12-2024 1:40 p.m. Surveyor observed Resident #268 voice to COTA Q that she was hungry and thirsty. Resident #268 pointed to the water cup on her bedside table and asked COTA Q to give her water, COTA Q told her she had to ask her nurse first. COTA Q walked out of room. In an interview on 03-12-24 at 1:50 p.m., LVN N said when a new resident is admitted his/her charge nurse is responsible for the initial evaluation. She said during the initial assessment, the resident will be asked questions to determine the amount of assistance needed with their activities of daily living which would include eating. LVN N said they asked the resident can you eat by yourself or need assistance with eating. LVN N said if the resident is non-interviewable, they will follow the hospital recommendations until an OT evaluation was done. LVN N said the CNA's are responsible to report to their charge nurse the percentage of food the resident eats. LVN N said, she had not been advised by her CNA's Resident #268 was not eating her meals. In an interview on 03/13/2024 at 9:58 a.m., the Dietary Manager said Resident #268's percentage of meal intakes were as follows: 03/09/2024 between 51-75% for dinner 03/10/2024 between 25-50% for breakfast, lunch and dinner resident refused 03/11/2024 between 51-75% for breakfast, 76-100% for lunch, and 26-50% for dinner 03/12/2024 between 0-25% for breakfast, 0-25 % for lunch, and 51-75% for dinner An interview on 03/13/2024 at 5:30 p.m., ADON RN E said CNA J should have assisted Resident #268 with her breakfast and lunch on 03/12/2024. ADON RN E said by not assisting Resident #268 with her meals, could result in weight loss. ADON RN E said LVN's have been trained to inform the CNA's on residents care. Record Review of the facility's Activities of Daily Living (ADLs) policy dated 05/26/23 reflected: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and areas services will be provided for the following activities of daily living: 4. eating to include meals and snacks. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 2 of 3 residents (Resident #36 and Resident #57) reviewed for quality of care in that: 1. The facility failed to ensure Resident #36's oxygen was administered at 5.0 Lpm via trach mask as ordered by physician. 2. The facility failed to ensure Resident #36's suctioning equipment was set up/connected at bedside ready for use. 3. The facility failed to ensure Resident #57's O2 saturation levels were monitored in percentage as ordered. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of Resident #36's admission Record dated 03/13/24 documented a [AGE] year-old female, on hospice, initially admitted on [DATE], readmitted on [DATE], with the diagnoses that included epilepsy with status epilepticus (A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minute period, without returning to a normal level of consciousness between episodes), respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), tracheostomy (an opening surgically created through the neck into the trachea, windpipe, to allow air to fill the lungs), intracranial injury with loss of consciousness of unspecified duration, amputation at level between right hip and knee, cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), atherosclerosis (the deposit of plaques of fatty material on the inner walls of arteries), hypertension (high blood pressure), acquired absence of right leg below knee, functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), amputation of right leg below the knee, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left hand, right hand, left wrist, right wrist, left knee. Record review of Resident #36's admission Minimum Data Set assessment dated [DATE] revealed Resident #36 had unclear speech, rarely/never understood others, rarely/never was understood by others, BIMS score of 03, indicating severe cognitive impairment, and was always incontinent of bowel and bladder. Record review of Resident #36's comprehensive care plan dated 01/04/24 revealed: FOCUS: Resident #36 had oxygen therapy Date Initiated: 01/21/2021 Revision on: 01/21/2021 GOALS: o The resident will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 01/21/2021 Target Date: 04/03/2024 INTERVENTIONS/TASKS: OXYGEN SETTINGS: O2 via trach collar @ 5 LPM Date Initiated: 01/21/2021 Revision on: 01/21/2021. FOCUS: Resident #36 had a tracheostomy Date Initiated: 01/21/2021 Revision on: 01/21/2021 GOALS: o The resident will have clear and equal breath sounds bilaterally through the review date. Date Initiated: 01/21/2021 Target Date: 04/03/2024 o The resident will have no abnormal drainage around trach site through the review date. Date Initiated: 01/21/2021 Target Date: 04/03/2024 INTERVENTIONS/TASKS: OXYGEN SETTINGS: O2 via Trach collar @ 5 LPM Date Initiated: 01/21/2021 Revision on: 01/21/2021 Record review of physician's order dated 01/14/21 revealed: Order Summary: O2 @5LPM VIA ANSO TRACHE COLLAR (type of tracheostomy collar) every shift for ACUTE RESPIRATORY FAILURE Observation on 03/11/24 at 10:00 a.m. revealed Resident #36 was lying in bed with head of bed inclined. O2 set at 4.5 Lpm via trach. Suction canister not hooked up. Suction equipment sitting clean at bedside. Observation on 03/13/24 at 02:37 p.m., Resident #36 lying in bed with head of bed inclined. O2 set on 4.5 Lpm. Suction canister not hooked up. Suction equipment sitting clean at bedside. In an interview on 03/13/24 at 02:55 p.m., RN C went to Resident #36's room. RN C confirmed Resident #36's O2 was set on 4.5 Lpm when it should have been set on 5 Lpm. RN C stated O2 machine settings should be checked at the beginning of every shift. RN C stated she was PRN working at the facility and worked there about once a month. RN C stated today (03/13/24) was her once-a-month day PRN at the facility. RN C stated the ball (on the O2 machine meter) should be read at the top (of the ball) for the O2 setting. RN C stated the suction canister should be set up at all times in case of emergency. RN C stated they must have changed the suction canister out and did not set it up. In an interview on 03/13/24 at 03:06 p.m., LVN B, day shift nurse for Resident #36, stated she checked O2 settings for residents throughout the whole day. LVN B stated for the ball meter on the oxygen machine, the liters were to be set to the middle of the ball. LVN B stated Resident #36's O2 order was for 5 Lpm. LVN B stated at 01:30-01:40 p.m., (03/13/24), she checked the Lpm on the O2 for Resident #36, and it was set at 5 Lpm. She said RN C was with her and could verify. LVN B stated she did not know if anyone had gone in the room to change the setting. LVN B verified O2 setting was less than 5 Lpm. LVN B stated resident's oxygen saturation could drop if the O2 was not set per the physician's order. LVN B stated she checked O2 saturations every shift. LVN B stated during nebulizer treatment, they documented all vital signs including O2 saturation. LVN stated the canister equipment was on the bedside table, but was not set up ready to go because Resident #36 never needed to be suctioned. In a telephone interview on 03/13/24 at 05:17 p.m., RT F stated she had to suction Resident #36. RT F stated the canister was supposed to be connected and ready to go at all times. RT F stated if the doctor's order was for 5 Lpm, the O2 should have been set on 5 Lpm. RT F stated if the O2 was set lower, there would be a possibility of resident desatting (low blood oxygen). In an interview on 03/13/24 at 06:36 p.m., ADON RN E (DON was on vacation) stated the O2 ball meter was read to the middle of the ball (to read an oxygen flow meter ball, the ball flow meter measurements should be taken from the middle of the ball) to set the flow rate in liters. ADON RN E stated if the O2 was less than ordered, the oxygen saturation would go down. ADON RN E stated at the worst, the resident could experience respiratory distress. ADON RN E stated the oxygen machines were to be checked every shift and as needed. ADON RN E stated as for the canister for suctioning a resident with a trach, the canister had to be set up, connected, and ready to go. ADON RN E stated it was not ok for it to be sitting there not connected. ADON RN E stated with the canister not being connected and ready to go, the resident could go into respiratory distress and they would not be ready (to suction the resident's airway). ADON RN E stated nurses were in-serviced at least once when new nurses and they were reminded all the time of trach care. 2. Review of Resident #57's admission Record dated 03/13/24 documented a [AGE] year-old female, on hospice, initially admitted on [DATE], with the diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus with hyperglycemia (occurs when a person's blood sugar elevates to potentially dangerous levels), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), hypertension (high blood pressure), parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), and bipolar II disorder (characterized by depressive and hypomanic episodes). Record review of Resident #57's Quarterly Minimum Data Set, dated [DATE] revealed Resident #57 had unclear speech, usually understood others, usually was understood by others, BIMS score of 05, indicating severe cognitive impairment, and was always incontinent of bowel and bladder. Record review of Resident #57's comprehensive care plan dated 12/28/23 revealed: FOCUS: Resident #57 has c/o COUGH/CONGESTION at times INTERVENTIONS/TASKS: Monitor o2 sats as ordered FOCUS: Resident #57 has OXYGEN therapy GOALS: o The resident will have no s/sx of poor oxygen absorption through the review date. INTERVENTIONS/TASKS: o Check O2 saturation levels as ordered o Monitor for s/sx of respiratory distress and report to MD/Hospice PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. o OXYGEN SETTINGS: O2 via nasal cannula @ 2LPM. Record review of Physician's Order dated 04/20/23 revealed: Oxygen Saturation - Check (frequency): MAINTAIN O2 ABOVE 92% every shift for hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level) Record review of Physician's Order dated 01/29/24 revealed: Oxygen Saturation - Check every shift every shift for hypoxia Record review of Resident #57's Weights and Vitals O2 Sat Summary from PCC revealed the following documentation: 12/26/2023 02:51 a.m. 98.0% @ 2 L/Min 01/08/2024 11:34 a.m. 98.0 % Oxygen via Nasal Cannula 02/08/2024 10:31 a.m. 97.0% Room Air 03/08/2024 01:36 p.m. 96.0% Oxygen via Nasal Cannula 03/12/2024 12:29 p.m. 94.0% Oxygen via Nasal Cannula Record review of Resident #57's March 2024 MAR/TAR revealed check marks only for the above orders. There were not oxygen saturation percentages on the March 2024 MAR/TAR for any shift on any day. There were check off marks only. In an interview on 03/12/24 at 03:20 p.m., ADON LVN D stated if there was an order for O2 saturations to be checked every shift or as needed, it (O2 saturations) would be documented under weights and vitals in PCC, and a percentage would be put in. ADON LVN D stated if the percentage was not put in the computer, the resident could desat, and no one would know the resident was desatting which would not be good for the resident. In an interview on 03/13/24 at 03:06 p.m., LVN B stated resident's oxygen saturation could drop if the O2 was not set per the physician's order. LVN B stated she checked O2 saturations every shift. LVN stated they documented all vital signs including O2 saturation on PCC either on the MAR/TAR or Weights & Vitals. In a telephone interview on 03/13/24 at 05:17 p.m., RT F stated if the doctor ordered monitoring of the O2 saturation, O2 saturation should be documented in percentage because that is how it is read, in percentage. RT F stated if the O2 saturation was not documented in percentage, how would they know if the resident was desatting. RT F stated O2 sats were always in percentages. In an interview on 03/13/24 at 06:36 p.m., ADON RN E stated that if there were an order to monitor O2 sats, it would be documented in the MAR and also in Weights and Vitals in PCC. ADON RN E stated if O2 saturations were not documented in percentage, they would not know the baseline. ADON RN E stated O2 sats were always in percentages. Review of the facility's Oxygen - policy and procedures was requested. Facility copied pages out of Lippincott's Manual to give to surveyor. No policies were given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure medications and biologicals were stored in locked compartments for one of eight residents (Resident # 50) reviewed for medication storage. The facility failed [NAME] prevent Resident #50 from having medication at his bedside for his personal use. This failure placed residents at risk of accidental and adverse medication reactions. Findings included: Record review of Resident #50's admission record dated 0/13/24 reflected Resident # 50 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cirrhosis of liver (scarring of the liver by chronic liver diseases), and diabetes (sustained high sugar levels.) Record review of Resident #50's quarterly MDS assessment dated [DATE], reflected a BIMS score of 10 out of 15 which indicated moderately cognitive impairment (decisions poor; cues/supervision required.) Record review of Resident #50's comprehensive care plans dated 01/18/24, reflected focus area, has an ADL self-care performance deficit r/t CVA effects impaired balance/coordination, and cognitive deficits. Interventions included skin inspection; the resident requires skin inspection with care and PRN, observe for redness, open areas , scratches , cuts, bruises and report changes to the nurse, revised on 10/04/22. Resident #50's care plans reflected no evidence resident would self-medicate. Record review of Resident #50's physician orders dated 03/12/24, revealed no physician's order to self-administer medications. During an observation on 03/11/24 at 10:50 am, Resident #50 was observed sitting on his bed. A tube of medication Gelmicin, (anti-fungal, antimicrobial, and anti-inflammatory), 40 mg (tube cream) was observed on top of his overbed table. The medication tube was approximately full. The medication administration on the tube indicated 0.5 mg. Interview on 03/11/24 at 10:55 am with Resident #50 revealed he used the medication Gelmicin for itching on his arms and legs. Resident #50 said FM J brought his medication from Mexico because he wanted to use that medication for his itching. Resident #50 said he did not know if any other skin cream was applied by staff for his itching skin. Resident #50 said staff were aware that he used the cream for his itching skin. Interview on 03/11/24 at 11:06 am with CNA G revealed she knew that Resident #50's FM J brought him the medication Gelmicin, from Mexico because he liked to use for his itching skin in his arms and legs. CNA G said she had not reported this incident to the charge nurse because she thought he already knew about this medication that the resident kept in his cabinet drawer. Resident #50 had been using the medication for some time. Interview on 03/11/24 at 1:57 pm with LVN H revealed FM J would bring in Gelmicin medication for the resident to use for his skin itching. LVN H said he had spoken to FM J several times that resident could not have the medication for personal use unless it was prescribed by his physician. LVN H said he had called Resident #50's physician so he could order a similar medicine for skin itching but the doctor had not responded to the request. LVN H said he had informed the DON and MDS/LVN I but no one had addressed it. LVN H said the medication Gelmicin was not care planned. He said he had removed the medication from Resident #50's personal possession several times but FM J kept bringing the medication back to the resident. Interview on 03/12/24 at 3:20 pm with ADON/LVN D revealed residents were not allowed to keep their own medications unless they were permitted by a doctor's order. ADON/LVN D said Resident #50 did not have an order to self-administer any medication. ADON/LVN D said they educated family members to inform the staff if they brought in medications for residents. ADON/LVN D said she had not seen any documentation in Resident #50's clinical chart that FM J was bringing in some medications for him or that staff had knowledge that Resident #50 had a medication for his personal use. Interview on 03/12/24 at 3:30 pm with LVN H revealed he had not documented any notes or information that Resident #50 had FM J bring in a medication to use for his skin itching or that he had called Resident #50's physician to prescribe another medication for the skin itching for Resident #50. LVN H said he had called Resident #50's physician on 03/12/24 to ask for a medication for skin itching for Resident #50 and his physician gave orders for ammonium lactate to treat dry skin for the itching. LVN H said he had removed Resident #50's Gelmicin medication yesterday and FM J had called him and asked if he could return the medication back to Resident #50. LVN H told FM J she could not continue to bring in the medication. LVN H said he had obtained orders for another medication for the dry skin and itching. Record review of a change of condition form dated 03/11/24 at 5:58 pm completed by LVN H for Resident #50 reflected a change in condition due to resident complaining of skin dryness to bilateral arms and legs and indicated the condition had not occurred before. Additional notes in the change of condition form reflected resident noted with dryness, reports itching to bilateral arms and legs. Notified doctor and received new order for ammonium lactate daily for dry skin. Interview on 03/13/24 at 2:06 pm with ADON/LVN D revealed the failure to address medications that were brought in for personal use by residents placed residents at risk at risk for an allergic reaction, depending on types of medications. ADON/LVN D said staff should have documented in resident's clinical charts the incident that Resident #50 had medications for his personal use and notify the DON. LVN H had not documented any notes in Resident #50's clinical chart. Interview on 03/14/24 at 11:40 am with ADON/RN E revealed residents were not allowed to keep medications in their rooms. Staff should contact the resident's physician to obtain orders for a medication that can be made available. ADON/RN E said she was not aware of Resident #50's use of his personal medication Gelmicin that FM J had brought to Resident #50. LVN H had not mentioned this incident to anyone else. LVN H should have informed the DON and documented on his nurse's notes. LVN H should have assessed Resident #50 and obtained medications from his physician. ADON/RN E said staff were required to do rounds and look for medications in resident's possession. Record review of the facility's policy titled Medication Administration dated 10/01/19 reflected. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare medications. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for one of eight (Resident #50) residents reviewed for clinical records in that: The facility failed to document in Resident #50's clinical chart that Resident #50 had family bring in medications for his personal use. This failure could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. Finding included: Record review of Resident #50's admission record dated 0/13/24 reflected Resident # 50 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cirrhosis of liver (scarring of the liver by chronic liver diseases), and diabetes (sustained high sugar levels.) Record review of Resident #50's quarterly MDS assessment dated [DATE], reflected a BIMS score of 10 out of 15 which indicated moderately cognitive impairment (decisions poor; cues/supervision required.) Record review of Resident #50's comprehensive care plans dated 01/18/24, reflected focus area, has an ADL self-care performance deficit r/t CVA effects impaired balance/coordination, and cognitive deficits. Interventions included skin inspection; the resident requires skin inspection with care and PRN, observe for redness, open areas , scratches , cuts, bruises and report changes to the nurse, revised on 10/04/22. Resident #50's care plans reflected no evidence resident would self-medicate. Record review of Resident #50's physician orders dated 03/12/24, revealed no physician's order to self-administer medications. During an observation on 03/11/24 at 10:50 am, Resident #50 was observed sitting on his bed. A tube of medication Gelmicin, (anti-fungal, antimicrobial, and anti-inflammatory), 40 mg (tube cream) was observed on top of his overbed table. The medication tube was approximately full. The medication administration on the tube indicated 0.5 mg. Interview on 03/11/24 at 10:55 am with Resident #50 revealed he used the medication Gelmicin for itching on his arms and legs. Resident #50 said his FM J brought his medication from Mexico because he wanted to use that medication for his itching. Resident #50 said he did not know if any other skin cream was applied by staff for his itching skin. Resident #50 said staff were aware that he used the cream for his itching skin. Interview on 03/11/24 at 11:06 am with CNA G revealed she knew that FM J brought him the medication Gelmicin, from Mexico because he liked to use for his itching skin in his arms and legs. CNA G said she had not reported this incident to the charge nurse because she thought he already knew about this medication that the resident kept in his cabinet drawer. Resident #50 had been using the medication for some time. Interview on 03/11/24 at 1:57 pm with LVN H revealed FM J would bring in Gelmicin medication for the resident to use for his skin itching. LVN H said he had spoken to FM J several times that resident could not have the medication for personal use unless it was prescribed by his physician. LVN H said he had called Resident #50's physician so he could order a similar medicine for skin itching but the doctor had not responded to the request. LVN H said he had informed the DON and MDS/LVN I but no one had addressed it. He said he had removed the medication from Resident #50's personal possession several times but FM J kept bringing the medication back to the resident. Interview on 03/12/24 at 3:20 pm with ADON/LVN D revealed residents were not allowed to keep their own medications unless they were permitted by a doctor's order. ADON/LVN D said Resident #50 did not have an order to self-administer any medication. ADON/LVN D said they educated family members to inform the staff if they brought in medications for residents. ADON/LVN D said she had not seen any documentation in Resident #50's clinical chart that FM J was bringing in some medications for him or that staff had knowledge that Resident #50 had a medication for his personal use. Interview on 03/12/24 at 3:30 pm with LVN H revealed he had not documented any notes or information that FM J bring in a medication to use for his skin itching or that he had called Resident #50's physician to prescribe another medication for the skin itching for Resident #50. LVN H said he had called Resident #50's physician on 03/12/24 to ask for a medication for skin itching for Resident #50 and his physician gave orders for ammonium lactate to treat dry skin for the itching. LVN H said he had removed Resident #50's Gelmicin medication yesterday and FM J had called him and asked if he could return the medication back to Resident #50. LVN H told FM J she could not continue to bring in the medication. LVN H said he had obtained orders for another medication for the dry skin and itching. Record review of a change of condition form dated 03/11/24 at 5:58 pm completed by LVN H for Resident #50 reflected a change in condition due to resident complaining of skin dryness to bilateral arms and legs and indicated the condition had not occurred before. Additional notes in the change of condition form reflected resident noted with dryness, reports itching to bilateral arms and legs. Notified doctor and received new order for ammonium lactate daily for dry skin. Interview on 03/13/24 at 2:06 pm with ADON/LVN D revealed that failure to address medications that were brought in for personal use by residents placed residents at risk at risk for an allergic reaction, depending on types of medications. ADON/LVN D said staff should have documented in resident's clinical charts the incident that Resident #50 had medications for his personal use and notify the DON. LVN H had not documented any notes in Resident #50's clinical chart. Interview on 03/14/24 at 11:40 am with ADON/RN E revealed residents were not allowed to keep medications in their rooms. Staff should contact the resident's physician to obtain orders for a medication that can be made available. ADON/RN E said she was not aware of Resident #50's use of his personal medication Gelmicin that FM J had brought to Resident #50. LVN H had not mentioned this incident anyone else. LVN H should have informed the DON and documented on his nurse's notes. LVN H should have assessed Resident #50 and obtained medications from his physician. ADON/RN E said staff were required to do rounds and look for medications in resident's possession. Record review of the facility's policy titled Documentation in Medical Record dated 10/24/22 reflected Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician acted upon and documented his or her rationale in the resident's medical record to the pharmacist report of any irregularities for 3 of 8 Residents (Resident #35, Resident #58, and Resident #87) whose records were reviewed for pharmacy services. 1.The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation to evaluate the effectiveness and continued use of Lorazepam (anti-anxiety), Hydroxyzine (antihistamine used to treat itching, anxiety, or sleepiness), and Clonazepam (treatment for seizures and panic disorder) for Resident #35. 2.The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation to evaluate the effectiveness and continued use of Omeprazole (treatment of gastroesophageal reflux disease) for Resident #58. 3.The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation to evaluate the effectiveness and continued use of Lithium (anti-psychotic and treatment for bipolar disease and major depressive disorder,) and Zyprexa (anti-psychotic , used to treat schizophrenia and bipolar disorder) for Resident # 87. This deficient practice could affect any resident and could result in resident's receiving psychotropic medications longer than required. The findings were: 1.Record review of the physician order summary dated 03/13/24 for Resident #35 reflected resident was admitted on [DATE], was a [AGE] year-old female with diagnosis which included convulsions (a sudden, violent irregular movement), functional quadriplegia (loss of motor and/or sensory function), delusion disorders (mental illness, paranoia), tremors, anxiety (unpleasant state of inner turmoil), diabetes (high blood sugar levels), major depressive disorder and was under hospice care. Orders included. -Clonazepam , 0.25 mg give one tablet by mouth two times a day for anxiety, start date 07/22/23. -hydroxyzine HCI oral tablet 50 mg, give 2 tablets by mouth three times a day for anxiety, start date 07/19/23. -Lorazepam oral concentrate 2 mg/ml. give 0.5 ml by mouth every 4 hours as needed for anxiety, start date 01/01/24. No stop date was indicated. Record review of the significant change MDS assessment dated [DATE] for Resident # 35 reflected. -BIMS score was 08 (cognitive status was moderately impaired , decisions poor; cues/supervision required,) -received anti-anxiety diuretic and opioid medications in the last seven days. Record review of comprehensive care plans dated 10/19/23 for Resident #35 reflected resident used anxiety medications and interventions included. -administer medications as ordered. -monitor behavior episodes PRN and attempt to determine underlying cause. -monitor the resident for safety. Record review of the physician communications form dated 02/28/24 for Resident #35 reflected the pharmacist consultant recommended CMS Mega Rule Phase II-PRN orders for psychotropic drugs are limited to14 days, except if the prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Prescriber should document the rationale in the resident's medical record and indicated the duration for the PRN order. Current medication: Lorazepam PRN anxiety. The recommendation rationale from hospice physician was not obtained until 03/13/24 after surveyor intervention. The response indicated to continue with the PRN order for 14 days. Record review of the physician communications form dated 01/30/24 for Resident #35 reflected the pharmacist consultant recommended anxiolytic gradual dose reduction attempt for Clonazepam 0.25 mg bid and Hydroxyzine 100 mg tid. All agents following within the psychoactive category (without regard to indication) fall under gradual dose reduction guidelines. This includes agents within the anxiolytic category. Please address the appropriate response below. The pharmacist consultant recommendation was signed by the hospice physician on 03/13/24 after surveyor intervention. The physician's response was an attempted GDR is likely to result in impairment of function or increased decreased behavior. 2.Record review of the physician order summary dated 03/31/24 for Resident #58 reflected Resident #38 was admitted on [DATE], was a [AGE] year-old male with diagnosis that included diabetes (sustained high blood sugar levels) , heart failure, gastro-esophageal reflux disease without esophagitis (digestive disorder), and anxiety. An order for Prilosec OTC (omeprazole) tablet delayed, give one tablet by mouth one time a day related to gastro-esophageal reflux disease, start date 11/21/23. Record review of the quarterly MDS dated [DATE] for Resident #58 reflected his BMIS score was 15 (cognitive status was independent (decisions consistent/reasonable). Record review of the comprehensive care plans dated for Resident 35 reflected resident had GERD, dated 04/04/22. Interventions included to give medications as ordered. Monitor and document side effects and effectiveness PRN, dated 04/04/22 and obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated. Record review of the comprehensive care plan dated 04/04/22 for Resident #58 reflected resident had GERD. Interventions included to monitor vital signs as ordered, PRN and notify MD of significant abnormalities. Record review of the physician communications form dated 01/30/24 for Resident #58 reflected the pharmacist consultant recommendation Omeprazole 20 mg daily for GERD since 11/21/23. The recommended duration based on the indications for PPIs is 4-8 weeks per product labeling and CMS. Long term use has been associated with increased risk of C. Diff Colitis, CAP, and B12 deficiency. The pharmacist consultant recommendation was responded on 03/13/24 by Resident #58's physician to discontinue medication and add Famotidine 20mg BID, PRN for indigestion and heartburn. 3.Record review of the physician order summary dated 03/31/24 for Resident #87 reflected Resident #87 was admitted on [DATE], was a [AGE] year-old female with diagnosis that included anxiety disorder (uncontrollable feelings of anxiety), diabetes (high blood sugar levels), chronic kidney disease (gradual loss of kidney functions), major depressive disorder (causes persistent sadness), bipolar disorder (causes extreme moods), and insomnia (sleeplessness). An order for Lithium carbonate ER oral tablet extended release 450 mg, give one tablet by mouth one time a day for bipolar disorder, start date 02/21/24. An order for Zyprexa oral tablet 5 mg (olanzapine),give 2 tablets by mouth two times a day for anxiety, start date 03/09/24. Record review of the quarterly MDS dated [DATE] for Resident #87 reflected. -BMIS score was 15 (cognitive status was independent (decisions consistent/reasonable). -received antipsychotic, antidepressant, antibiotic, insulin medications in the last seven days. -gradual dose reduction had not been attempted. Record review of the comprehensive care plans dated for Resident #87 reflected resident used anti-psychotic medications related to bipolar disorder, date initiated 07/07/23. Interventions included monitoring for lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels, follow up for prompt and accurate serum lithium determinations should be available before initiating therapy. Resident used antipsychotic medication related to bipolar disorder, date initiated 07/07/23. Interventions included to administer medications as ordered per MD, dated 07/07/23 and monitor/document/report PRN any adverse reactions of antipsychotic medications and pharmacy consultant to review medications at least monthly, dated 07/07/23. Record review of the physician communications form dated 02/28/24 for Resident #87 reflected. Resident currently receives an antipsychotic; Lithium ER 450mg daily for bipolar and Zyprexa 5 mg bid for anxiety. Please review the continued use of this antipsychotic. The pharmacist consultant recommendations had not been addressed by the resident's physician and documented 3/13/24; pending call back from doctor. Interview on 03/13/24 at 9:25 am with ADON/LVN D revealed LVN R was responsible to call the doctors for all pharmacy consultant recommendations and she was currently out on leave. ADON/LVN D said Medical Records Q would get the recommendations from LVN R after she had obtained a response from the doctors. Medical Records Q would download the completed pharmacy consultant recommendations in each resident's clinical chart. Interview on 03/13/24 at 2:02 pm with ADON/LVN D revealed the pharmacy consultant recommendations for Resident #35, Resident #58 and Resident #87 had not been completed with the response by their respective doctors. ADON/LVN D said she was not sure why they had not been completed. Interview on 03/13/24 at 2:55 pm with the Pharmacy Consultant revealed he expected the facility to contact the respective physicians for Resident #35, Resident #58, and Resident #87 in a timely manner. Each resident had different recommendations, but they should have been responded by their doctors as soon as possible. Interview on 03/14/24 at 11:49 am with ADON/RN E revealed the pharmacy consultant recommendations should have been addressed and acted on as soon as the doctor was called and contacted. A follow up to get the response from the physicians should be made as soon as possible. ADON/RN E said the DON who was on leave, was responsible to ensure the staff were getting the responses from the doctors as soon as possible. ADON/RN said the failure to obtain a response for the recommendations could have had adverse effects on the medication administration of each medication for Resident #35, Resident #58, and Resident #87. Record review of the facility policy's titled Consultant Pharmacist Services and Reports dated 10/01/19 reflected The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.

**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 were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for one of eight residents (Resident #35) reviewed in that. The facility to continue to administer the psychotropic medication Lorazepam 0.5mg PRN after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropics that placed residents at risk of experiencing adverse drug reactions. The findings include: Record review of the physician order summary dated 03/13/24 for Resident #35 reflected resident was admitted on [DATE], was a [AGE] year-old female with diagnosis which included convulsions (a sudden, violent irregular movement), functional quadriplegia (loss of motor and/or sensory function), delusion disorders (mental illness, paranoia), tremors, anxiety (unpleasant state of inner turmoil), diabetes (high blood sugar levels), major depressive disorder and was under hospice care. An order for Lorazepam oral concentrate 2 mg/ml. give 0.5 ml by mouth every 4 hours as needed for anxiety, start date 01/01/24. No stop date was indicated. Record review of the MARs dated January 2024, February 2024 and March 2024 reflected Resident #35 received the medication Lorazepam PRN on 01/01/24 01/02/24 01/03/24 01/15/24 01/16/24 01/20/24 01/30/24 02/02/24 02/03/24 02/09/24 02/11/24 02/18/24. No medication was administered in the month of March 2024. Record review of the significant change MDS assessment dated [DATE] for Resident # 35 reflected. -BIMS score was 08 (cognitive status was moderately impaired , decisions poor; cues/supervision required,) -received anti-anxiety diuretic and opioid medications in the last seven days. Record review of comprehensive care plans dated 10/19/23 for Resident #35 reflected resident used anxiety medications and interventions included. -administer medications as ordered. -monitor behavior episodes PRN and attempt to determine underlying cause. -monitor the resident for safety. Record review of the physician communications form dated 02/28/24 for Resident #35 reflected the pharmacist consultant recommended CMS Mega Rule Phase II-PRN orders for psychotropic drugs are limited to14 days, except if the prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Prescriber should document the rationale in the resident's medical record and indicated the duration for the PRN order. Current medication: Lorazepam PRN anxiety. The recommendation rationale from hospice physician was not obtained until 03/13/24 after surveyor intervention. The response indicated to continue with the PRN order for 14 days. Interview on 03/13/24 at 9:25 am with ADON/LVN D revealed LVN R was responsible to call the doctors for all pharmacy consultant recommendations and she was currently out on leave. ADON/LVN D said Medical Records Q would get the recommendations from LVN R after she had obtained a response from the doctors. Interview on 03/13/24 at 2:02 pm with ADON/LVN D revealed the pharmacy consultant recommendations for Resident #35 had not been completed with the response by their respective doctors. ADON/LVN D said she was not sure why they had not been completed. The order for medication Lorazepam was PRN and did not have a stop date as it was required. Interview on 03/13/24 at 2:55 pm with the Pharmacy Consultant revealed he had recommended a stop date for Lorazepam and had expected the facility to contact the respective physicians for Resident #35 in a timely manner to review the order for a psychotropic medication Lorazepam. Interview on 03/14/24 at 11:49 am with ADON/RN E revealed the pharmacy consultant recommendation for Resident #35 should have been addressed and acted on as soon as the doctor was called and contacted. ADON/RN said the failure to obtain a response for the recommendation could have had adverse effects on the medication administration of the PRN medication, Lorazepam for Resident #35. Record review of the facility policy titled Psychotropic Medication dated 08/15/22 reflected Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication (s). PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration, (i.e.) 14 days.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to remove 27 gallons of water that were past the use by date from their emergency drinking water supply. This failure could place residents at risk of foodborne illnesses. The findings included: In an observation of the kitchen on 03/11/2024 beginning at 9:10 a.m., revealed there were 27 gallons of water dated 01-11-23 and a use by date of 08/31/2023 stored in the back of the kitchen where the emergency water supply was stored. An interview on 03/13/2024 at 9:30 a.m., the Dietary Manage said the current emergency water supply had been there prior to her being hired. The Dietary Manager said she would remove the expired water gallons immediately and replace them with new ones. The Dietary Manger did not say if resident's could be negatively affected by drinking water past the use by date. An interview on 03/13/2024 at 4:30 p.m., the Administrator said he would make sure the expired water gallons were removed and replaced as soon as possible. Record review of facility's Emergency and Disaster Planning dated 10/01/2018 and revised on 06/19/2019 revealed: Policy: The facility is committed to ensuring that it's residents, staff and any incoming residents from other facilities are provided with adequate nutrition during emergencies or natural disasters. Water: Emergency water supplies must be stored under sanitary conditions and must meet the following criteria: a. The containers of drinking water must be dated and not expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview the facility failed appropriate treatment and services were received for 1 (Resident #100) of 6 residents with bowel and bladder incontinence, in that: The WCN did not perform hand hygiene between donning and doffing gloves when performing incontinent care for Resident #100. CNA A and the WCN did not use a clean technique or use clean wipes when performing pericare on Resident #100, wiping back to front. CNA A and CNA B did not wash their hands for a minimum of 20 seconds during pericare. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #100's Face Sheet dated 01/06/23 reflected an [AGE] year-old female admitted to the facility on [DATE], diagnoses included: Pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), stage 3 (the sore has gone through all layers of skin into the fat tissue, exposing the resident to infection), aftercare following joint replacement (right hip), and dementia. Record review of Resident #100's Admission/Medicare 5-Day MDS dated [DATE] reflected: Extensive assistance with 2+ person assistance was needed for bed mobility, transfers, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Resident #100 was frequently incontinent of bowel and bladder. Record review of Resident #100's Care Plan dated 11/21/22 reflected: -Resident #100 had a STAGE 3 pressure ulcer to her sacrum with intervention of : Follow facility policies/protocols for the prevention/treatment of skin breakdown. -Resident #100 had bowel and bladder incontinence with interventions of: The resident used disposable briefs. Change as needed; Clean peri-area with each incontinence episode; Check as required for incontinence. Wash, rinse, and dry perineum (the thin layer of skin between your genitals - vaginal opening or scrotum - and anus). Change clothing PRN after incontinence episodes. Review of Resident #100's Weekly Pressure Ulcer Evaluation dated 01/04/23 reflected Resident #100's stage 3 sacral pressure ulcer measurement as 4.0cm x 2.5cm x 0.2cm. 12/10/22 Weekly Pressure Ulcer Evaluation documented Resident #100's stage 3 sacral pressure ulcer measurement as 4.0cm x 5.0cm x 0.2cm. Observation on 01/06/23 at 02:26 p.m., during incontinent care for Resident #100 revealed CNA B wiped Resident #100's anal area four times with the same wipe swiping back to front with one swipe. CNA B wiped the resident's anal area three times with the same wipe. CNA B removed gloves and washed her hands for 13 seconds. After washing her hands, CNA B put on new gloves. CNA B removed her gloves. CNA B left the room to get more supplies. CNA B returned to the room and washed her hands for 13 seconds. CNA B put on new gloves. CNA B rolled the linen to the resident's backside on the left. CNA A removed her gloves, used hand sanitizer, and put on new gloves. CNA B placed a clean adult brief and mattress pad under the resident's left side, under soiled linen. Resident #100 soiled the clean mattress pad. CNA B rolled the resident to her left side. CNA A gathered the soiled linen and pulled it to right side. CNA B attached the tabs on adult brief. CNA A removed her gloves and washed her hands for 8 seconds and put on clean gloves. CNA B removed her gloves, washed her hands for 17 seconds, and put on new gloves. CNA B rolled resident to right side and CNA B tucked mattress pad under left side. CNA B rolled resident to left side and CNA A held resident on left side. CNA B pulled clean mattress pad to right side. CNA A removed gloves, used hand sanitizer, and put on new gloves. CNA B put clean pillowcase on pillow. CNA B rolled resident to left and CNA A placed pillow under right side. CNA A rolled resident to right side and CNA B put pillow under left side. CNA A lifted feet and legs and CNA B placed pillow under feet and between legs. CNA A and CNA B covered resident with clean sheet and blanket. CNA B raised head of bed and lowered bed. CNA B removed gloves, washed hands for 22 seconds. CNA A removed gloves and washed hands for 48 seconds. CNAs left room. Interview on 01/06/23 at 10:33 a.m. CNA A stated 30 seconds was the handwashing time. CNA A stated she washed her hands for 30 seconds the first time, but she did not know (how long she washed her hands) for the other times. CNA A stated they were to use one wipe for each swipe. CNA A stated infection could occur if she did not wash her hands for 30 seconds. CNA A said CNA B (CNA Charge) checked them off once a week for pericare. Interview on 01/06/23 at 10:37 a.m. CNA B stated they were to wash their hands for 30 seconds. CNA B stated she thought she washed her hands for 30 seconds each time she washed her hands. CNA B stated she was to use one wipe for each swipe and wipe from front to back. CNA B stated infection could occur if using the same wipe more than once and wiping back to front could cause infection. CNA B stated CNAs were in-serviced (by ADONs) maybe once a week and she (CNA B) checks the other CNAs. CNA B stated she is the Charge CNA who checks the other CNAs during pericare. Wound care observation on 01/06/23 at 10:52 a.m., revealed the WCN sprayed the sacral pressure ulcer with wound cleaner and patted dry. The WCN removed her gloves, put on new gloves. No hand sanitizer was used before putting on new gloves. The WCN applied Santyl, Gentamicin and, collagen powder to sacral pressure ulcer. The WCN covered sacral pressure ulcer with gauze and covered with Optifoam dressing. The WCN removed her gloves, did not perform hand hygiene, and put on new gloves. The WCN placed a clean adult brief under Resident #100's soiled brief. Resident #100 had a moderate bowel movement. CNA B removed her gloves, used hand sanitizer, and put on new gloves. The WCN removed her gloves and put on new gloves. No hand sanitizer used before putting on new gloves. The WCN wiped anal area front to back with one wipe removing bowel movement with five swipes, then using the same wipe and wiped back to front twice. The WCN removed her gloves and put on new gloves. WCN did not use hand sanitizer before putting on new gloves. CNA B wiped anal area with one wipe removing feces. CNA B removed her gloves, washed her hands for 34 seconds. The WCN wiped anal area using one wipe for four swipes back to front attempting to get the feces off, under the dressing. The WCN removed the dressing she had applied over the sacral pressure ulcer before the resident had a moderate bowel movement. The WCN sprayed Resident #100's wound with wound cleaner and patted dry. The WCN removed her gloves and put on new gloves without using hand sanitizer. The WCN applied Santyl/Gentamicin/Collagen, covered with gauze, and applied Optiform dressing to sacral pressure ulcer. Dressing was dated and initialed by WCN. The WCN removed her gloves and put on new gloves not using hand sanitizer. CNA B attached the adult brief tab on the right side and the WCN attached the adult brief tab on left side. Interview on 01/06/23 at 11:31 a.m. the WCN stated she was supposed to sanitize her hands before putting on new gloves. She stated she was nervous and forgot. WCN stated contamination can occur if she does not use hand sanitizer before putting on new gloves. The WCN stated she is to use one wipe for each swipe with a front to back motion. She stated they are in-serviced on infection control that includes handwashing/hand sanitizer. Interview on 01/06/23 at 01:57 p.m. CNA C stated 20-30 seconds is the handwashing time per policy. CNA C stated check-offs on handwashing are done frequently. CNA C did not know how often. CNA C stated hand sanitizer is used when gloves are removed and before putting on new gloves. CNA C stated when care has been provided, CNA C said she washes her hands. CNA C stated one wipe is used per swipe during pericare and CNAs are to wipe front to back. CNA C stated CNA B does check-offs and so does the ADON. Interview on 01/06/23 at 02:04 p.m. CNA D stated handwashing time is 20 seconds. CNA D stated when changing gloves during resident care, the CNA can either wash their hands before putting on new gloves or use hand sanitizer. CNA D stated they are to use one wipe per swipe when doing pericare. CNA D stated they wipe front to back. CNA D stated if those things are not followed, infection or cross-contamination can occur. CNA D stated check-offs and in-services on pericare or handwashing do not occur often, but when they do, it is either a nurse or CNA B who does the check-off. Interview on 01/06/23 at 02:14 p.m. the DON stated the handwashing policy was soap and water for at least 20 seconds. DON stated after using antibacterial hand sanitizer two to three times, wash hands. The DON stated one wipe should be used per swipe and they are to wipe front to back. The DON stated when changing gloves, hand sanitizer is to be used before putting on clean gloves. DON said the negative outcome is the potential for infection is greatly increased. DON stated the ADON does the check-offs for new hires, yearly, or as needed. DON stated in-services occur very often, especially with COVID-19. Record review of facility's CNA Orientation Skills Checklist including Pericare/Females and Handwashing/Gloves dated 03/31/22, revealed completion by CNA A and CNA B. Record review of facility's Basics of Hand Hygiene, dated 04/11/22 revealed Basics of Hand Hygiene was completed by CNA A. Record review of facility's Basics of Hand Hygiene, dated 04/20/22 revealed Basics of Hand Hygiene was completed by CNA B. Record review of facility's In-service Training Report for CNAs and Nursing on Handwashing dated 12/21/22, revealed CNA A and CNA B attended the training. Review of facility's perineal care revealed; [Corporate name], dated 10/24/22, Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Definition 'Perineal care' refers to the care of the external genitalia and the anal area. Policy Explanation and Compliance Guidelines: 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males using a separate washcloth or wipes. b. Thoroughly dry. Record review of facility's hand hygiene policy revealed: [Corporate name] dated 10/24/22 Hand Hygiene Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: 'Hand hygiene' is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1.Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 5.Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of hands and fingers. 6.Additional considerations: a. Then use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of How to Perform Perineal Care (https://cna.plus/faq/promotion-of-health/perineal-care-how-to/) on 01/06/2023 revealed: 5. Cleanse the perineum, using front to back motions. Use a fresh washcloth for each pass from front to back. 6. Never wash back to front; this causes contamination and can cause infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral feeding received the appropriate treatment and services to prevent potential complications for two (Resident #61 and Resident # 45) of 3 residents reviewed with feeding tubes in that; 1)The facility did not ensure Resident #61's enteral feeding formula (fed through gastric tube) and water bag were not initialed, date and time started and name of formula and water bag for tube feeding were not labeled when first placed and as required by standard of care. 2) The facility did not ensure Resident #45's enteral feeding water bag was not initialed, dated, or timed when first placed and as required by standard of care. These failures could place residents with feeding tubes at risk for dehydration or calorie deficiency. Findings included: 1)Record review of the admission record for Resident # 61 dated 01/04/23 indicated Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with diagnosis that included parkinson's disease (progressive disorder that affects nervous system), alzheimer's disease (common type of dementia), dysphagia (difficulty in swallowing), dementia (impaired ability to remember), abnormal weight loss and polydipsia (excessive thirst or excess drinking). Record review of Resident #61's quarterly MDS dated [DATE] indicated. -cognitive skills were moderately impaired, -required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use, -required extensive assistance by one person for personal hygiene and -received 51% or more of total calories through tube feeding. Record review of Resident #61's Physician Orders dated 01/04/23 indicated an order. Every shift (Jevity 1.2) at (65ml per hour), via G-tube stationary pump. Feeding to provide (Total 1710 Kcals, 79.2 gm protein, 300ml of free water, total fluids 1730ml, start date, 11/21/22. Record review of care plan revised on 11/25/22 indicated Resident #61 required use of peg tube for all nourishment and hydration needs. During an observation on 01/03/23 at 10:35 am Resident #61was lying in bed with G-tube feeding turned off. The formula bottle had 250ml left in the bottle of formula labeled Jevity 1.2 and the water bag contained 200ml of water. Both the formula bag and water bag had no information labeled such as date it was started, time started, name of formula or the initials of the staff who placed the formula and water bag for Resident #61. Interview on 01/03/23 at 11:33 am with LVN G she said both the formula bottle and water bag should be labeled with date started, time started, name of formula, and initials of the staff who had placed the new feeding bottle and water bag. LVN G said the night nurse, LVN H had placed the new feeding bag and water bag. LVN G said she had come in late during the morning and had not done her rounds for the morning. LVN G said she had not seen the formula and water bag missing the labels that they required. LVN G said Resident #61 feeding was on downtime. Interview on 01/06/23 at 4:04 pm with LVN H revealed she had not noticed she forgot to label the feeding bottle and water bag for Resident #61. LVN H said if the feeding bottle and water bag are not labeled with date, time, name of formula or initials of staff who started the feeding, staff might not be able to know if the resident was getting less or more feeding or water that was ordered by the physician. Record review of the admission record for Resident # 45 dated 01/05/23 indicated Resident 45 was admitted to the facility on [DATE] with diagnosis that included encephalopathy (altered mental state), end stage renal disease (permanent stage of kidney disease), diabetes (metabolic disorders caused by high blood sugars), dysphagia (difficulty in swallowing), and urinary tract infection. Record review of Resident #45's admission MDS dated [DATE] indicated. -cognitive status was moderately impaired, -required extensive assistance by two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. -received 25% or more of total calories through tube feeding. Record review of Resident #45's Physician Orders dated 01/04/23 indicated an order. Every shift (Jevity 1.5) at (60ml per hour), via G-tube stationary pump, continuous for 20 hours. 75ml H2) flush Q4hrs. Downtime; 3pm -7pm, start date 12/25/22. Record review of care plan revised on 12/27/22 indicated Resident #45 required use of tube feeding related to dysphagia. During an observation on 01/04/23 at 8:58 am, Resident #45 was lying in bed with G-tube feeding on at 60ml per hour. The formula bag was labeled with name of formula, Jevity 1.5, dated 01/04/23 and time of start and the staff initials. The water bag did not have a date started, or timed or initials of staff who started the feeding bag and water bag. Interview on 01/04/23 at 9:10 am with LVN I revealed the night nurse LVN J had started the tube feeding formula and water bag but had not labeled the water bag with date started, or time started and the initials. LVN I said she did rounds in the morning and did not notice the water bag for tube feeding for Resident #45 was not labeled. LVN I said both the feeding and water bag should be labeled to be sure the feeding and water were dispensed as ordered. Interview on 01/04/23 at 3;30 pm with LVN J revealed he had remembered to label the water bag with date of start and time and his initials for Resident #45. LVN J said if the feeding bags or water bags are not labeled, staff will not know when the feedings were started or by who and if the feeding bags are dispensing as ordered. Interview on 01/05/23 at 4:10 pm with the facility DON revealed the feeding and water bags should be labeled with date initiated, correct formula, resident name, rate of administration, time of start and initials of staff who started the feeding. The DON said she had no policy or procedure on labeling of the feeding and water bags, and she had not in-serviced her staff on the proper procedure of labeling the feeding and water bags. The DON said she would start in-servicing her staff on the proper procedure to label the feeding and water bag.

Based on observation and interview, the facility failed to ensure that the residents' right to view survey results were readily accessible to residents, family members and legal representatives of residents for 1 of 1 facility reviewed. The facility failed to retain any previous survey results dating back the last previous years 2019 -2022 within the survey binder for residents to review. This failure could place residents and visitors at risk of not being aware of the facility's past deficiencies. Findings included: Observation on 1/4/23 of the survey binder contained the last investigation dated 9/21/21. No other surveys or investigations dated after were found in binder. Record review of ASPEN Central Office revealed that last recertification survey was conducted on 10/21/21 and two other investigations thereafter dated 6/2022 and 1/2022 were conducted yet were not in found in survey binder. In an interview on 1/4/23 at 10:47 am the Administrator said he is the one in charge of updating the Survey Binder and said he could not tell why he had not updated it. In an interview on 1/5/23 at 3:47 pm the Administrator said the residents, family and visitors have a right to be able to see the recent surveys and the binder is supposed to be updated. He also said they did not have a policy for updating the survey binder.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: The boxes of dry goods, bread, vegetables, and paper goods were placed directly on the floor in the pantry instead of on pallets. This deficient practice could place residents who received meals from the kitchen at risk of food-borne illness. The findings were: Observation during initial tour of the kitchen with the [NAME] on 01/03/23 at 9:15 AM revealed 14 boxes that included canned fruit and vegetables, sugar packets, flour, salt, and rice on the floor in the pantry. The [NAME] said the delivery from the food distributor had just arrived. Observation on 01/03/23 at 9:19 AM revealed the delivery driver from the food distributor had placed three more boxes of foam cups, plastic cutlery, and canned vegetables in the pantry. In an interview on 01/03/22 at 9:20 AM, the Delivery Driver said he had been given instructions by his supervisor to put the boxes on pallets, but he had not seen any pallets in the pantry so, he placed the cases on the floor. In an interview on 01/03/23 at 9:21 AM, the [NAME] said the delivery from the food distributor had just arrived and the driver had put them on the floor. The [NAME] said the boxes should be up on pallets. The [NAME] said there were three staff working in the kitchen, the cook, the dietary aide, and the dishwasher. The [NAME] said no one had been assigned to put away the deliveries; all staff had to assist with putting the deliveries away. The [NAME] said the deliveries should be put on a pallet, but the drivers were in a hurry and didn't put them on a pallet. In an interview on 01/03/23 at 2:02 PM, the DC said he had in-serviced the staff on ensuring that they instructed the driver to place all deliveries on a pallet. The DC said he placed two pallets in the janitors closet for easy access. The DC said he told the dietary staff to be a little more forceful with the drivers when they dropped of the deliveries. The DC said it was important to keep the food off the floor to prevent cross contamination and prevent food borne illnesses. Record review of a policy on Food Storage revised on 06/01/19 indicated: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP Guidelines. Procedure: h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination.