Based on staff interview, review of medical records, and review of the policy and procedures, facility staff did not report to the State Agency bruising of unknown origin for 1 resident in the sample of 5. (Resident identifier: 1.) Findings include: A nursing note, dated January 27, 2025, for resident 1, noted that staff found bruising to the neck, back and sides. On 2/5/2025, the licensor interviewed Admin 1. Admin 1 stated the bruising to resident 1 ' s back and sides were present at the time of admission to the facility. Admin 1 stated that resident 1 was assessed and that the bruising to the anterior neck was caused by a shirt that resident 1 was wearing. Admin 1 stated that resident 1 was admitted to the hospital with a new diagnosis of hemophilia, which contributed to the bruising. Admin 1 stated because of the shirt and new diagnosis, resident 1 did not have an injury of unknown origin and that a critical incident was not reported to the State Agency within one business day as required. The licensor reviewed the facility ' s Abuse Reporting Policy which indicated that the state licensing/certification agency responsible for surveying/licensing the facility was to be notified within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. On 2/5/2025 at 9:40 AM, the licensor conducted an interview with Admin 1. Admin 1 stated that the incident of unknown bruising was not reported to the office.

Based on observation, interview, record review, and facility policy review, the facility failed to provide fingernail care for 1 (Resident #15) of 2 residents sampled for activities of daily living (ADLs). Findings included: A review of a facility policy titled Fingernails/Toenails, Care of, dated February 2018, revealed The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy revealed, General Guidelines. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed and 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The policy further revealed, The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care. 3. The condition of the resident's nails and nail bed. The policy revealed documentation should also include 4. Any difficulties in cutting the resident's nails. 5. Any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure. 6. If the resident refused the treatment, the reason(s) why and the intervention taken. A review of Resident #15's admission Record revealed the facility admitted the resident on 12/09/2022 with diagnoses including dementia and peripheral vascular disease (narrowed arteries). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/16/2023, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required extensive staff assistance with bed mobility, transfers, locomotion on and off their unit, dressing, toilet use, and personal hygiene. The MDS revealed the resident was totally dependent on staff for bathing. A review of Resident #15's care plan revealed a focus statement, revised on 06/06/2023, that indicated the resident had an ADL self-care performance deficit related to abnormal gait and balance, confusion, dementia, and weakness. The care plan revealed the resident required partial assistance with personal hygiene and interventions included instructions for staff to provide assistance. The care plan revealed the resident required total assistance with bathing, and interventions included instructions for staff to provide assistance. The care plan contained instructions for staff to report to a nurse if the resident refused care, evaluate for the potential causes and barriers, ask the resident why they were refusing, and attempt alternative approaches. An observation on 11/27/2023 at 10:27 AM revealed Resident #15's fingernails were long and appeared dirty. An observation on 11/27/2023 at 12:25 PM revealed Resident #15's fingernails were long with a brown substance under five of them. An observation on 11/28/2023 at 12:30 PM revealed Resident #15's fingernails were long and appeared dirty. An observation on 11/29/2023 at 11:05 AM revealed Resident #15's fingernails were long and brownish-colored. During an interview on 11/29/2023 at 11:41 AM, Certified Nursing Assistant (CNA) #1 stated Resident #15's nails were dirty. CNA #1 said staff should provide nail care and clean residents' nails if they appeared dirty. During an interview on 11/29/2023 at 11:59 AM, CNA #2 stated all personal care for residents should be completed during showers. She stated personal care included shaving and cleaning fingernails, noting she thought CNAs could cut fingernails, if needed. CNA #2 stated she had not provided a shower for Resident #15, but noted the resident did not refuse care. She stated if a resident refused care, it should be documented and reported to the Director of Nursing (DON). She stated when a resident refused, three different CNAs were to offer to provide care at different times to the resident, noting then a nurse would offer care. She said when a resident refused care, facility staff were supposed to document the refusals on a refusal form and in the electronic medical record. During an observation with CNA #2 on 11/29/2023 at 12:10 PM, CNA #2 stated Resident #15's fingernails were very long and needed care. During an interview on 11/30/2023 at 9:28 AM, CNA #4 stated Resident #15 received showers on the night shift, noting she gave the resident a shower a couple of weeks prior. CNA #4 stated she did not clean or cut Resident #15's fingernails during the shower in question because she did not think she was supposed to. During an observation and interview on 11/29/2023 at 12:18 PM, Registered Nurse (RN) #3 inspected Resident #15's nails and stated the resident's nails needed care. After Resident #15 stated their fingernails were tender, RN #3 expressed that the resident had possibly refused nail care due to nail tenderness. She stated if the resident had refused nail care, it should have been reported to a nurse. During an observation and interview on 11/29/2023 at 12:48 PM, the DON observed Resident #15's fingernails and said the resident's nails need to be cleaned and cut. She stated the resident's nails needed to be cleaned and cut on the resident's shower days. She stated if a resident refused care, a nurse should be informed. During an interview on 11/30/2023 at 9:03 AM, the Administrator stated he expected nail care to be offered with showers. The Administrator stated he spoke to some staff who said they had offered nail care and Resident #15 refused, but the refusals were not documented. The Administrator stated he observed Resident #15's nails before they were cleaned and cut and thought it had been longer than a couple of weeks since the resident's nails had been cut.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the review it was determined, for 2 of 15 sample residents, the facility did not ensure that patient privacy was protected. Specifically, another resident's name was used in another residents medical record. Resident identifier: 4 and 35. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses which included hypertension, reflux, Parkinson's disease and muscle weakness. Resident 4's record was reviewed on 11/28/21. A nurses note dated 11/28/21 stated LPN (Licensed Practical Nurse) [1] and RN (Registered Nurse) [1] came from different hallways and noted [Resident 4's name] and other resident [Resident 35's name] on the floor laying next to each other in the living room by the nurses station. On 11/30/21 at 10:34 AM, an interview was conducted with RN 3. RN 3 stated that when charting resident names were not used to protect the privacy of all residents. On 12/01/21 at 10:53 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that staff members should not be charting other resident's names in the chart. The DON stated that both residents were best friends and were getting up to take a walk together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not ensure that all allegations involving abuse were reported no later than 2 hour after the allegation was made but no later than 24 hours if the event that cause the allegation did not involve abuse or did not result in bodily injury. The finial investigation was provide to the State Survey Agency within 5 working days of the incident. Specifically, an incident involving a report of verbal abuse was not reported to the State Survey Agency (SSA) or investigated for 10 days after the incident. Resident identifier: 37. Findings include: Resident 37 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of the right femur, fracture of right ulna, and urinary tract infection. A review of the facility reported incident revealed that the facility contacted the State Agency on 7/16/21 regarding an incident that occurred on 7/6/21. Resident 37's medical record was reviewed. A nursing progress note revealed on 7/6/21 at 3:55 AM, Pt (patient) complaining about nursing staff. Staff has taken care of each of pt's needs and requests. Pt is safe in bed. Staff has answered pt's call light each time in a timely manner. Staff spend over an hour in pt's room to help make pt. comfortable during last call light call. A Resident Advocate (RA) note dated 7/6/21 at 2:35 PM, Residents daughter and son in law came to RA's office with some concerns about how the night CNA's (Certified Nursing Assistant) had been acting on the night shift and their concerns for their mothers care. RA took these concerns to ADON (Assistant Director of Nursing), Administrator, PT (Physical Therapist) and DON (Director of Nursing). Staff will look into the concerns and do any disciplinary actions that are needed to fix any concerns. RA gave residents daughter her personal number to call her personally if there is any problems or concerns with her care. RA has followed up with staff and family to make sure there is communication and resolution with any concerns being taken care of. The final investigation for resident 37 was submitted to the SSA on 7/16/21. The timeline of events revealed that on 7/6/21 at 3:00 AM, a family member received a call from resident 37, who reported a CNA yelled at her. At 6:00 AM, the family member went to the facility and reported to the nurse that a resident 37 stated a night nurse yelled at her. At around 9:00 AM, the nurse notified the ADON and Administrator. At 9:30 AM, the family members returned to the facility to talk with the RA and report that resident 37 had called them during the night and reported a staff member yelled at her. At 10:00 AM, the RN notified the Administrator and the ADON of potential verbal abuse. At 12:00 PM, DON talked with the family and RA to address concerns regarding staff. The family told the DON and RA the same concerns as they did at 9:30 AM when they met with the RA. The DON told the family he would start an investigation. At 12:15 PM, the DON talked to resident 37, who answered no when asked if staff yelled at her last night. The DON Felt like she understood the questions and was alert and oriented. At 12:30 PM, the DON followed up with the RA and Administrator and It was decided that verbal abuse did not occur but we wanted to inform the Ombudsman of the situation and investigation. At 2:00 PM, the nurse called the ADON. The ADON interviewed the nurse. At 11:00 PM, the DON interviewed the CNA that was working the night of the allegation. On 7/7/21 the DON interviewed the other CNA and the DON follow up with the RA and Administrator regarding the findings. It was Determined that no verbal abuse occurred. On 11/30/21 at 11:33 AM, an interview was conducted with the RA. The RA stated that the facility staff investigated the incident on 7/6/21 as a potential abuse, because resident 37's family member reported verbal abuse by a staff member. The RA stated that the family member stated it was abuse because one of the staff members yelled at resident 37. The RA stated there was a call with the State Survey Agency Director because the ombudsman contacted the SSA. On 12/01/21 at 8:07 AM, an interview was conducted with the Administrator. The Administrator stated the facility completed an investigation and resident 37 said it wasn't abuse. The Administrator stated that he made the Ombudsman aware of the situation and the ombudsman talked to the State Survey Agency Director. The Administrator stated that the State Survey Agency Director had a conference call with the facility staff. The Administrator stated he was guided to report the abuse allegation and submit a final investigation. The Administrator stated he did not initially report the abuse because the investigation revealed there was no abuse within 2 hours of the report. The Administrator stated that he maybe learned about the abuse allegation about 9:00 AM but did not report by 11:00 AM because the resident stated she had not been yelled at. The Administrator stated that he did not report the abuse allegation because it was not abuse. [Note: The abuse allegation was reported to the nurse at 6:00 AM and there was no investigation within 2 hours.] On 12/1/21 at 9:00 AM, a follow up interview was conducted with the Administrator. The Administrator stated that he reviewed his timeline and he was made aware of the verbal abuse allegation at approximately 10:15 AM and was able to rule out abuse by 12:15 PM. The Administrator stated that the resident stated no one yelled at her so that was why it was not reported. The Administrator stated that he was not aware it was an abuse allegation when notified at 9:00 AM. The Administrator stated that all interviews were not completed within 2 hours but the allegation of abuse was unsubstantiated within 2 hours so there was no reason to report. The Administrator stated he reported the allegation and investigation to the SSA after the State Survey Agency Director instructed him to report it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 15 sample residents, assessment was not accurately reflect the resident's status. Specifically, a resident receiving hospice services was not reflected on the resident's assessment. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, chronic kidney disease, diabetes, hypertension, and major depressive disorder. Resident 9's medical record was reviewed on 11/30/21. The facility Matrix revealed that resident 9 was receiving hospice services. Resident 9's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was not receiving hospice care. There was no physician's order or care plan located in resident 9's medical record for hospice services. On 11/30/21 at 2:38 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 9 was receiving hospice services. RN 3 stated there should be an order and a card in the front of the resident's medical record with the hospice company and phone numbers. RN 3 stated that hospice companies leave notes in the resident's medical record. RN 3 stated resident 9 did not have notes and hospice staff communicated verbally with the facility staff. RN 3 stated there should be a plan of care regarding hospice and if there was not one, she would talk to the hospice company. On 11/30/21 at 3:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that there were phone numbers for hospice companies on the Report sheet that the nurses used. LPN 2 stated that I believe most of the time will communicate verbally with hospice companies. LPN 2 stated she was not familiar with care plans and was unable to find a hospice care plan in resident 9's medical record. On 11/30/21 at 2:50 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that she did comprehensive care plans with the MDS assessments. The MDS coordinator stated resident 9 received hospice services. The MDS coordinator stated that resident 9 had been receiving hospice services since at least March 2021. The MDS coordinator stated the hospice services should have been checked on the MDS in September 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan. Specifically, a resident did not have a hospice care plan. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, chronic kidney disease, diabetes, hypertension, and major depressive disorder. Resident 9's medical record was reviewed on 11/30/21. The facility Matrix revealed that resident 9 was receiving hospice services. Resident 9's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was not receiving hospice care. There was no physician's order or care plan located in resident 9's medical record for hospice services. On 11/30/21 at 2:38 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 9 was receiving hospice services. RN 3 stated there should be an order and a card in the front of the resident's medical record with the hospice company and phone numbers. RN 3 stated that hospice companies leave notes in the resident's medical record. RN 3 stated resident 9 did not have notes and hospice staff communicated verbally with the facility staff. RN 3 stated there should be a plan of care regarding hospice and if there was not one, she would talk to the hospice company. On 11/30/21 at 3:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that there were phone numbers for hospice companies on the Report sheet that the nurses used. LPN 2 stated that I believe most of the time will communicate verbally with hospice companies. LPN 2 stated she was not familiar with care plans and was unable to find a hospice care plan in resident 9's medical record. On 11/30/21 at 2:50 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that she did comprehensive care plans with the MDS assessments. The MDS coordinator stated resident 9 received hospice services. The MDS coordinator stated that resident 9 should have a care plan regarding hospice from the hospice agency. On 12/01/21 at 8:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated usually hospice nurses were in the building 2 to 3 times per week. The DON stated that the hospice nurses and aides verbally communicated with staff. The DON stated hospice care plans should be provided to the facility. The DON stated that she texted the hospice yesterday to have them send the care plan information and visit notes. On 12/1/21 at approximately 8:45 AM, the DON provided a physician's order from the hospice agency that revealed resident 9 was to receive hospice services. The order was dated 2/28/21. It should be noted that nursing staff were unable to find the physician's order in resident 9's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the review, for 1 of 15 sample residents, it was determined that the facility did not ensure that the qualified staff members were providing care for residents. Specifically, a nursing student provided assistance for a resident unsupervised by staff which resulted in an avoidable fall. Resident identifier: 18. Findings include: Resident 18 was admitted on [DATE] with diagnoses which included right femur fracture, history of falling, personal history of transient ischemic attack, and vertigo. Resident 18's medical record was reviewed on 11/30/21. A nurses note dated 10/30/21 at 11:11 AM stated Pt (Patient) had an assisted fall in the bathroom with nursing assistant students from [name of school]. Pt was wearing regular socks, no grippy socks or shoes were put on before taking her to the bathroom and her feet slipped, so the NA (Nursing Assistant) students helped her to the ground. They notified me of the assisted fall and stated that she did not hit her head. No injuries noted. VSS (Vital Signs Stable) WNL (within normal limit). Will continue to monitor A&O's (Alert and Orientation) for 12 hours. Pt placed on 72 hour fall charting. MD (Medical Doctor) notified. On 12/01/21 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that nursing students should not have been working with a resident without a staff member present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 15 sample residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used without adequate monitoring. Specifically, a resident with two blood pressure medications were administered when the pulse was outside of the physician ordered parameters. Resident identifier: 23. Findings include: Resident 23 was admitted to the facility on [DATE] with diagnoses which included epidural hemorrhage, arthrodesis, vertebra fracture, right wrist fracture, atrial fibrillation, non-specific low blood pressure reading and anxiety On 11/29/21 at 2:05 PM, an interview was conducted with resident 23. Resident 23 stated her blood pressure kept going down and she had to lay down to get her dizziness to go away. Resident 23 stated she did not think she had a change in medications. Resident 23's medical record was reviewed on 11/30/21. Physician's orders revealed the following medications: 1. On 8/29/21, Carvedilol Tablet 6.25 milligrams to give 1 tablet twice daily for atrial fibrillation and hypertension (HTN). The order further revealed to hold the medication if resident 23's systolic blood pressure (SBP) was less than 100, if diastolic blood pressure (DBP) was less than 50 or if resident 23's heart rate (HR) was less than 60. 2. On 8/30/21, Telmisartan Tablet to administer 20 milligram by mouth one time a day for HTN. The order further revealed to hold the medication for SBP less than 100, DBP less than 50 or HR less than 60. Resident 23's Medication Administration Records (MAR)were reviewed: 1. September 2021 MAR revealed the Carvedilol was administered when with the follow heart rates: a. On 9/13/21 with a heart rate of 58, b. On 9/14/21 with a heart rate of 57, c. On 9/16/21 with a heart rate of 59, d. On 9/19/21 with a heart rate of 50, e. On 9/20/21 with a heart rate of 57, f. On 9/21/21 with a heart rate of 56. The Telmisartan was administered: a. On 9/14/21 with a heart rate of 57, b. On 9/17/21 with a heart rate of 57, c. On 9/20/21 with a heart rate of 57 d. On 9/21/21 with a heart rate of 56, e. On 9/30/21 with a heart rate of 57. 2. The October 2021 MAR revealed the Carvedilol was administered when with the follow heart rates: a. On 10/8/21 with a heart rate of 58, b. On 10/14/21 with a heart rate of 59, c. On 10/23/21 with a heart rate of 58 d. On 10/25/21, the medication was administered twice with a heart rates of 58 and 54. The Telmisartan was administered: a. On 10/14/21 with a heart rate of 59, b. On 10/23/21 with a heart rate of 58, c. On 10/25/21 with a heart rate of 58, d. On 10/26/21 with a heart rate of 57, e. On 10/28/21 with a heart rate of 57. 3. The November 2021 MAR revealed the Carvedilol was administered when with the follow heart rates: a. On 11/9/21, the medication was administered twice with a heart rates of 55 and 56, b. On 11/10/21 with a heart rate of 57, c. On 11/15/21 with a heart rate of 58, d. On 11/21/21 with a heart rate of 59, e. On 11/24/21 with a heart rate of 59, f. On 11/30/21 with a heart rate of 57. The Telmisartan was administered: a. On 11/2/21 with a heart rate of 54, b. On 11/9/21 with a heart rate of 55, c. On 11/10/21 with a heart rate of 57, d. On 11/24/21 with a heart rate of 59. On 12/1/21 at 8:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that blood pressure medications should be administered according to physician's orders. The DON stated if the medication had parameters, the the parameters should be followed. The DON stated that if the heart rate was outside of the parameters the medications should not be administered. The DON stated the medications should have been held.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility did not conduct COVID-19 testing of staff as frequently as required based on the parameters set forth by the Centers for Disease Control and Prevention (CDC). In addition, the facility did not document that staff testing was completed and the results of each staff test. Specifically, a staff member that was unvaccinated was not tested twice weekly when working at the facility. Findings include: On 12/01/21 at 10:15 AM, the staff testing was reviewed. A calendar provided by the facility revealed on 11/15/21 the COVID-19 county transmission rate was 19.8% which was red. On 11/22/21 the COVID-19 county transmission rate was 19.2% which was red. The facility was on outbreak testing for all staff. Record showed that on 11/29/21 the COVID-19 county transmission rate was 16.5% which was red and the facility was in outbreak testing for all staff. Staff member (SM) 4's testing was reviewed. SM 4 was documented as unvaccinated on the paperwork provided by the facility. The testing results revealed that SM 4 had a COVID-19 test on 11/21/21 where she tested positive. The testing results further revealed that SM 4 tested negative on 11/18/21. There was no other testing documented for SM 4 on the form provided. SM 4's work schedule was reviewed. SM 4 worked on 11/3/21, 11/6/21, 11/7/21, 11/10/21 and 11/14/21. On 12/01/21 at 12:21 PM, Human Resources (HR) Director was interviewed. HR Director stated that the facility was currently in outbreak status and all staff were required to have a COVID-19 test performed twice per week. HR Director stated that there was no documentation that SM 4 was tested for COVID-19 on the shifts worked prior to 11/18/21. HR Director stated that night shift staff had verbalized they were completing COVID-19 testing but did not document testing or test results. HR Director stated that SM 4 had been told she would be taken off the schedule if she did not start completing COVID-19 testing twice weekly, so she tested on [DATE].

Based upon interview and record review it was determined that the facility did not ensure that the Infection Preventionist (IP) had completed specialized training in infection prevention and control. Specifically, the designated IP had not completed the designated training. Findings include: On 12/01/21 at 8:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was the Infection Preventionist (IP) for the facility. The DON stated she had not completed the specialized training from the Centers for Disease Control and Prevention (CDC) as she was new to her position as DON. The DON stated that the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) nurse were also new to their positions and had not completed the specialized training either.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 21 sampled residents, that the facility did not immediately consult with the resident's physician if a significant charge in the resident's physical, mental or psychosocial status occurred. Specifically, a resident's physician was not notified of pain during wound dressing changes and another resident's physician was not notified when a resident experienced a change of condition. Resident identifiers: 23 and 86. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower and right lower limb, right and left feet with fat layers exposed, chronic kidney disease, hypothyroidism, and unspecified dementia. On 9/10/19 at 9:36 AM, resident 23 was interviewed. Resident 23 stated that his feet hurt like a Son of a gun when staff changed the dressing. Resident 23 stated that medication did not touch the pain. On 9/10/19 at 3:05 PM, resident 23 was interviewed. Resident 23 stated that that his feet hurt. Resident 23 stated that he had to ask for pain medication but the medication did not work. Resident 23 stated it hurt like a son of a gun when the nurses changed the bandages on his feet. Resident 23 stated that he would like stronger pain medication before his feet were touched. Resident 23 stated that he did not always receive medication before the bandages were changed. Resident 23's feet were observed to be covered with his toes exposed. Resident 23's toes were observed swollen and the toe nails were pulling up from the skin. The area between resident 23's toes was observed to be a blackish yellow with open wounds between the toes. There was some cotton observed between the toes. Resident 23's medical record was reviewed on 9/10/19. A care plan dated 8/13/19, revealed [Resident 23] has potential for alteration in comfort r/t (related to) chronic ulcers of lower extremities, current infection, limited mobility. One of the goals developed was, The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. An intervention developed was, Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Resident 23's August 2019 Medication Administration Record (MAR) was reviewed and revealed the following: a. A Physician's order dated 8/13/19, Gabapentin Capsule 300 MG (milligrams) Give 1 capsule by mouth three times a day related to cellulitis of left lower limb. The order was discontinued on 9/6/19. b. An active Physician's order dated 8/18/19, Tylenol Extra Strength 500 MG.Give 2 tablet by mouth every 8 hours as needed for pain related to non-pressure chronic ulcer of other part of right foot with fat layer exposed. Resident's pain was documented when the Tylenol was administered. Resident 23's pain was an 8 on 8/20/19, 8/27/19, and 8/31/19. Resident 23's September 2019 MAR was reviewed and revealed the following: a. A Physician's order dated 9/6/19, Gabapentin Capsule 300 MG Give 600 mg by mouth three times a day related to cellulitis of left lower limb. b. Resident 23's documented pain level was a 5 or 6 from 9/1/19 through 9/9/19. On 9/10/19 at 4:06 PM, an observation was made of resident 23. Resident 23 was observed in his wheelchair in his room. Registered Nurse (RN) 1 was observed to enter resident 23's room with Licensed Practical Nurse (LPN) 1. RN 1 was observed to kneel on the ground in front of resident 23. LPN 1 was observed to kneel to the left side of resident 23. RN 1 stated to the surveyor as he started to cut off the dressing on the left foot that, it's quiet painful for him. Resident 23 was observed throughout the dressing change grimacing, putting his shoulders by his ears, taking deep breathes, closing his eyes, flinching and pulling his foot away. During the observation of the dressing change resident 23 stated his pain was at an 8. RN 1 was observed to offer resident 23 pain medication when the dressing change was over and resident 23 stated Nah. On 9/10/19 at 4:52 PM, the Director of Nursing (DON) was observed to ask resident 23 about his pain. The DON used a facial chart to show resident 23 different pain levels. Resident 23 was observed to point to the 6 and stated he was at a 6. Resident 23's progress notes revealed the following entries: a. On 8/15/19 at 10:04 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. Resident exhibits non-verbal signs of pain. b. On 8/16/19 at 7:03 AM, .Pain: Patient verbalizes pain. Patient rates pain 8 on a scale of 0-10. c. On 8/17/19 at 2:05 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. d. On 8/17/19 at 7:03 AM, .Pain: Patient does not verbalize pain. Resident exhibits non-verbal signs of pain. Grimacing. e. On 8/19/19 at 5:23 PM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. bilateral feet Resident exhibits non-verbal signs of pain. f. On 8/19/19 5:49 PM, .Wound care done to bilateral feet. Pt (patient) did better at elevating feet this afternoon, c/o (complaints of) pain in feet which was managed with tylenol. g. On 8/19/19 at 10:52 PM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. h. On 8/20/19 at 6:38 AM, .Pain: Patient verbalizes pain. Patient rates pain 8 on a scale of 0-10. bilateral feet pain managed with prn (as needed) tylenol Resident exhibits non-verbal signs of pain. i. On 8/22/19 at 10:32 AM, .Pain: Patient verbalizes pain. Patient rates pain 3 on a scale of 0-10. Resident exhibits non-verbal signs of pain. j. On 8/24/19 at 6:43 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. bilateral feet Pain managed with prn tylenol and positioning. Resident exhibits non-verbal signs of pain. k. On 8/24/19 at 1:42 PM, .Pt's pain level is baseline, c/o pain in bilateral feet. Tylenol used to manage pain. l. On 8/25/19 at 6:40 AM, .Pain: Patient verbalizes pain. Patient rates pain 6 on a scale of 0-10. bilateral feet Resident exhibits non-verbal signs of pain. m. On 8/25/19 at 3:43 PM, .Pt's pain level is baseline, c/o pain in bilateral feet. Tylenol used to manage pain. He reports increased pain during wound care, while wearing boots, and when feet are elevated. Pt educated on importance of elevating feet and keeping heels floated for wound healing and 4+ weeping edema. Though pt is non-compliant with those orders, when reminded he makes more effort to try to be compliant. n. On 8/26/19 at 12:25 AM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. bilateral feet Resident exhibits non-verbal signs of pain. o. On 8/26/19 at 6:47 AM, .Pain: Patient verbalizes pain. Patient rates pain 8 on a scale of 0-10. bilateral feet Pt experienced increased pain this morning from normal. Resident exhibits non-verbal signs of pain. sharp, shooting, achy. p. On 8/28/19 at 6:25 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. bilateral feet Tylenol 1000 mg given for pain. Pain worse during wound care. Resident exhibits non-verbal signs of pain. q. On 8/30/19 at 1:16 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. BLE (bilateral lower extremities). r. On 8/31/19 at 1:59 AM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. BLE . s. On 9/2/19 at 2:56 PM, Pt was give 2 500mg tablets of tylenol 30 minutes prior to changing his dressings on his feet. pt shows through facial expression and stating that he is in a lot of pain. Pt constantly pulls his legs in toward him while doing his wounds. t. On 9/3/19 at 1:01 AM, .Pain: Patient does not verbalize pain. Patient rates pain 0 on a scale of 0-10. Resident exhibits non-verbal signs of pain. non verbal display of grimacing and withdrawal. u. On 9/3/19 at 6:53 AM, .Pain: Patient verbalizes pain. Patient rates pain 6 on a scale of 0-10. BLE Pt c/o BLE pain, especially during wound care. Resident exhibits non-verbal signs of pain. v. On 9/4/19 at 6:40 AM, .Pain: Patient verbalizes pain. Patient rates pain 7 on a scale of 0-10. general achy,sharp Resident exhibits non-verbal signs of pain. holds breath, grunts, grimaces. w. On 9/5/19 at 7:07 AM, .Pain: Patient verbalizes pain. Patient rates pain 4 on a scale of 0-10. BLE Resident exhibits non-verbal signs of pain. x. On 9/5/19 at 2:25 PM, a physicians note from Medical Doctor (MD) 1 revealed, .Plan: .Pain due to severe peripheral vascular disease, wounds, neuropathy - Increase gabapentin from 300mg TID (three times daily) to 600mg TID. y. On 9/6/19 at 12:26 AM, .Pain: Patient verbalizes pain. Patient rates pain 5 on a scale of 0-10. BLE. z. On 9/6/19 at 6:47 AM, .Pain: Patient verbalizes pain. Patient rates pain 7 on a scale of 0-10. BLE legs Resident exhibits non-verbal signs of pain. grimacing, guarding. aa. On 9/6/19 at 9:40 AM, pt c/o increased pain. MD increases gabapentin to 600mg TID. bb. On 9/7/19 at 6:30 AM, .Pain: Patient does not verbalize pain. Resident exhibits non-verbal signs of pain. grimaces. cc. On 9/8/19 at 6:49 AM, .Pain: Patient verbalizes pain. Patient rates pain 7 on a scale of 0-10. bilateral feet pt c/o foot pain which is increased with wound care and elevation. Resident exhibits non-verbal signs of pain. dd. On 9/9/19 at 6:50 AM, .Pain: Patient verbalizes pain. Patient rates pain 6 on a scale of 0-10. bilateral feet Increased pain with wound care. Resident exhibits non-verbal signs of pain. ee. On 9/10/19 at 4:20 AM, .Pain: Patient does not verbalize pain. Patient rates pain 0 on a scale of 0-10. [Note: There was no documentation that resident 23's physician had been notified of non-verbal signs of pain or when resident 23 verbalized pain.] A form titled Doctor Communication Form dated that it was faxed on 9/2/19, revealed resident 23's name and Possible Narcotic PRN d/t (due to) severe pain during wound dressing change. There was no follow up information on the form. A form titled Doctor Communication Form' dated 9/4/19, revealed resident 23's name and Pain management? There was no follow up information on the form. [Note: The physician assessed the resident on 9/5/19 and increased the gabapentin. There was no other documentation that the physician was notified prior to 9/2/19 via the communication form.] On 9/10/19 at 5:00 PM, RN 1 was interviewed. RN 1 stated that he had just talked to the wound nurse about resident 23's pain. RN 1 stated that the facility recently hired a new set of physician's. RN 1 stated that he did not feel that the gabapentin helped with the pain during the dressing change and when resident 23 went to the wound clinic. RN 1 stated that the wound nurse told him that he was going to contact MD 1 regarding pain. RN 1 stated that MD 2 was contacted and he increased resident 23's gabapentin. RN 1 stated that the Nurse Practitioner asked for facility staff to contact MD 1 in regards to pain medication orders. RN 1 stated that resident 23 usually stated that he was okay during a dressing change but noticed his eyes were big and his body was stiff which demonstrated pain. On 9/11/19 at 7:19 AM, the Wound Nurse (WN) was interviewed. The WN stated that he talked to the wound care physician and the wound care physician told him he would send over an order for pain medication to administer before resident 23's wound care appointment. The WN stated that MD 1 ordered an increase in the gabapentin. The WN stated that was the first time he had contacted a physician regarding resident 23's pain. On 9/11/19 at 10:05 AM, an interview was conducted with MD 1. MD 1 stated that his first day in the facility was 9/5/19. MD 1 stated that he was notified of resident 23's pain for the first time on 9/5/19. MD 1 stated he talked with a nurse at the facility about resident 23's pain. MD 1 stated that he assessed resident 23's pain and resident 23 described pain that was more consistent with neuropathy. MD 1 stated that resident 23 described his pain as pins and needles. MD 1 stated that he increased resident 23's gabapentin to alleviate the pain. MD 1 stated that, I understand they (facility staff) were trying to control his pain and balance his pain with also not sedating him. MD 1 stated that he was unaware that resident 23 was experiencing pain during dressing changes and would have looked into that a little more and addressed that pain. On 9/11/19 at 10:13 AM, the DON was interviewed. The DON stated that he had not been notified that resident 23 was having pain during wound dressing changes. The DON stated that resident 23's pain during dressing changes should be directly communicated to the physician. The DON stated the nurses should call the physician or use the communication form to notify the physician regarding a resident's pain. On 9/11/19 at 10:41 AM, the DON was re-interviewed. The DON stated that he was unable to provide information that the physician was notified of pain prior to 9/2/19. The DON stated that the physician prior to 9/1/19 had not addressed resident 23's chronic pain. 2. Resident 86 was admitted to the facility on [DATE] with diagnoses which included left femur fracture, heart failure, diabetes mellitus, urinary tract infection, and urine retention. Resident 86's medical record was reviewed on 9/11/19. A nursing progress note dated 8/30/19 at 11:16 PM, revealed Pts (Patient's) wife vocalized concern to me that pt had started shaking in his hands and was concerned about him. Upon assessment his vitals were: Temp (temperature): 103.4 O2 (oxygen): 80% on 3 liters of oxygen Pulse: 112 and irregular Respirations: 24 BP (blood pressure):116/56. I increased his oxygen to 5 liters and the Pts O2 increased to 95%. I gave the pt PRN tylenol for the fever and removed his blankets. His pulse was above normal limits, but upon checking his history I found that he had a pulse this high regularly since being at this facility. Will continue to monitor closely throughout the night. Another nursing progress note dated 8/31/19 at 2:47 AM, revealed Pt is on 72 hr (hour) charting related to recent admission to facility following repair of left femur fracture. Pt had a fever of 103.4 at 2300 (11:00 PM) and an O2 sat (saturation) of 80%. Tylenol was given for fever and temp has been monitored hourly and has slowly declined. 0xygen was increased to 4 l (liters) and 02 sats increased to 95%. Will continue to monitor. Another nursing progress note dated 8/31/19 at 5:44 AM, revealed Continued to monitor pt throughout the night. Temp slowly dropped and I administered tylenol again at 0530 (5:30 AM). Pulse lowered and stayed in the 90s throughout the night. Oxygen levels continued to fluctuate from high 70s to mid 90s and I titrated oxygen as needed. Patient currently has a temp of 101.8 F (Fahrenheit) and oxygen levels of 95 at 4 L of oxygen via nasal cannula. It was also noted during the night the the patient's urine was a very dark reddish/brown color. We tried to push fluids throughout the night. Will continue to monitor. Another nursing progress note dated 8/31/19 at 9:20 AM, revealed Transfer to Hospital Summary Note Text: Pt was sent by ambulance to [local] hospital, His BP was declining, last taken was 75/45 with Paramedics which was decreased from morning vitals. His O2 sats were also declining. Overnight he was increased to 3L to maintain 90% but this AM at 5L was 81%. He was coming in and out of consciousness and had previously been complaining of increased pain throughout the night. He also had a temperature last night, which had improved and was WNL (within normal limits) this AM. Dr (doctor) notified and his recommendation was to send him to the ER (Emergency Room), pt SO (sic) was also notified. On 9/11/19 at 12:13 PM, LPN 2 was interviewed via the phone. LPN 2 stated that resident 86 had a decline at approximately 11:00 PM. LPN 2 stated that she monitored resident 86 during the night. LPN 2 stated that she did not notify the physician regarding a change in resident 86's condition. LPN 2 stated that she was not aware of the facility policy of when to notify the physician. LPN 2 stated that she passed the information regarding resident 86 on in report to the next nurse. On 9/11/19 at 12:42 PM, the DON was interviewed. The DON stated that the Physician should be notified if there was an incident of change in condition of a resident. The DON stated the Physician should have been contacted in the middle of the night regarding resident 86's change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated. Resident identifier: 30. Findings include: Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included chronic diastolic heart failure, atrial fibrillation, Parkinson's Disease, dementia with Lewy bodies, chronic obstructive pulmonary disease, localized edema, and acute kidney failure. Resident 30's medical record was reviewed on 9/10/19. On 9/11/19 at 10:15 AM, an interview was conducted with the Social Services Director (SSD). The SSD stated that resident 30 was not issued a NOMNC when his services were terminated and resident 30 became a long term care resident. The SSD stated that resident 30 had not used all of his Medicare days. The SSD stated that she had no further documentation to provide. On 9/16/19, the Administrator provided additional documentation. The form was dated 7/23/19, meeting regarding [Resident 30]. The form was signed by the Minimum Data Set Coordinator and a family member on 9/13/19. [Note: The date of the signature was after the survey team completed the survey.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, a resident that was a fall risk did not have a baseline care plan developed within 48 hours of the admission. Resident identifier: 11. Findings include: Resident 11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, severe protein calorie malnutrition, anxiety disorder, irritable bowel syndrome, muscle weakness, insomnia, and major depressive disorder. Resident 11's medical record was reviewed on 9/10/19. The care plans developed for resident 11 documented the following entries: a. A care plan Focus developed on 6/22/19, documented Primary Diagnosis: Alzheimer's, unspecified. A Goal developed was, Resident will obtain highest possible level of function for current prognosis. Interventions developed were, admission IDT (interdisciplinary team) meeting. Educate resident/family with changes in plan of care. Encourage to perform ADLs (activities of daily living) at max functional ability. Ensure therapeutic approach at all times. Evaluate every IDT and PRN (as needed). PT (physical therapy)/OT (occupational therapy) Evaluation & (and) treatment. b. A care plan Focus developed on 6/25/19, documented Restorative Nursing Resident: (has an actual ADL performance deficit) r/t (related to) contractures, difficulty with feeding. An additional Focus of, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t severe cognitive and communication deficits, and physical limitations. c. A care plan Focus developed on 6/26/19, documented Anxiety I get anxious sometimes, when I am in a new environment or when I do not recognize where I am. Adjustment - Long-Term It's difficult to accept the need to be in a long-term care facility. Insomnia I have trouble sleeping. And Discharge Plan - LTC (Long Term Care) Resident is planning to live here long term. d. A care plan Focus developed on 7/5/19, documented The resident has an ADL self-care performance deficit r/t Confusion Resident likes to take clothes off while out in the hall and in places where other residents are. e. A care plan Focus developed on 7/8/19, documented Socially Inappropriate - I take my clothes off in common areas. [Note: The baseline care plan must include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, social services, and Preadmission Screening and Resident Review recommendations, if applicable. The baseline care plan must be developed within 48 hours of the resident's admission.] An admission Minimum Data Set (MDS) assessment was signed as complete on 7/9/19. [Note: A comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment.] On 9/11/19 at 10:13 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that a baseline care plan was not initiated for resident 11. The MDS coordinator stated that he completes the comprehensive care plans for the residents. On 9/11/19 at 11:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the admitting nurse for the resident would complete the baseline care plan within 24 to 48 hours of admission. The DON stated that the resident care plan would be addressed at all the IDT's. The DON stated that the resident family, caregiver, and the resident would be included at the IDT. The DON stated that the floor nurse would be responsible for implementing the care plan. The DON further stated that the floor nurse was responsible for revising the care plan and implementing interventions where necessary. The DON stated that himself and the Assistant Director of Nursing would review the care plans and education would be provided to the staff where necessary. No additional information provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, a resident had not received a recertification visit since her admission to the facility. Resident identifier: 11. Findings include: Resident 11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, severe protein calorie malnutrition, anxiety disorder, irritable bowel syndrome, muscle weakness, insomnia, and major depressive disorder. Resident 11's medical record was reviewed on 9/10/19. Physician recertification visits for resident 11 were unable to be located in the medical record. On 9/10/19 at 1:57 PM, an interview was conducted with The Director of Nursing (DON). The DON stated that the Medical Director (MD) for the Skilled Nursing rehabilitation residents would visit the facility two times a week, and the MD for the Long Term Care residents would visit the facility once a week. The DON stated that on 9/1/19, the facility made a change in the MD. The DON stated that the two MDs would coordinate with each other to make sure the resident visits were completed timely. The DON stated that a calendar was generated by the Assistant Director of Nursing. The DON stated that the calendar would be given to the MDs so they would be aware when a resident recertification would need to be completed. The DON stated that the MD would document the visit in the progress notes section of the resident medical record. The DON stated that resident 11 had been followed by her attending physician since her admission to the facility. The DON stated that he had reached out to resident 11's physician to see if he had any visit notes. On 9/11/19 at 9:59 AM, a follow up interview was conducted with the DON. The DON stated that the Nurse Practitioner saw resident 11 yesterday on 9/10/19, for the first time at the facility. The DON stated that there were no physician visit notes prior to 9/10/19, for resident 11. [Note: The MD should have seen resident 11 at least once every 30 days for the first 90 days after admission. Resident 11 did not have a physician recertification visit for 81 days from admission.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not hold hypertensive medications when blood pressure and/or pulse measurements were outside of the physician ordered parameters. Resident identifier: 9. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses which included left femur fracture, left artificial hip joint, hypertension, mood disorder due to known physiological condition, history of falling, major depressive disorder, and dementia without behavioral disturbance. Resident 9's medical record was reviewed on 9/10/19. A physician's order dated 7/13/19, documented lisinopril 20 milligrams. Give 2 tablets daily related to hypertension. Hold for a systolic blood pressure (SBP) < (less than) 110, a diastolic blood pressure (DBP) <50, or a heart rate (HR) <60. Notify the Medical Director for a SBP > (greater than) 200, a DBP <40, or a HR >120. A review of the August and September 2019 Medication Administration Record (MAR) documented the following entries when resident 9's vital signs were below the physician ordered parameters and the lisinopril was administered: a. On 8/1/19, HR 59 b. On 8/6/19, DBP 48 c. On 8/9/19, HR 58 d. On 8/21/19, DBP 48 e. On 8/23/19, HR 56 f. On 8/24/19, HR 53 g. On 8/31/19, HR 54 h. On 9/6/19, HR 51 i. On 9/7/19, HR 53 j. On 9/9/19, HR 53 k. On 9/10/19, HR 58 On 9/11/19 at 9:09 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that if the resident's vital signs were below the physician ordered parameters she would administer the medication to the resident anyway. RN 2 stated that she would have the Certified Nursing Assistant retake the resident's vital signs. RN 2 stated that if the resident vital signs were redone she would document the new set of vital signs in a progress note. RN 2 stated that if the resident's vital signs were within the physician ordered parameters she would administer the medication and document the resident's vital signs on the MAR. On 9/11/19 at 9:37 AM, an interview was conducted with the Director of Nursing (DON). The DON provided no additional information regarding resident 9's lisinopril being administered outside of the physician ordered parameters. On 9/16/19, the Administrator submitted additional information for review via email. The Administrator documented that a plan of correction was created for unnecessary medications. The Administrator documented that the problem was identified and addressed in the August 2019 Quality Assurance. An Audit Review/Education Form was provided by the Administrator. The form documented a Chart Review/Medication Audit. Resident 9 was not identified by staff on the form as requiring a medication audit. The form documented Education given to nursing staff on medication audit and results. Plan of corrections in place and further audit reviews in place with additional education to nursing staff as needed. Nurses verbalize understanding of education and made corrections in documentation as needed. POC (Plan of Correction) and education given to nursing staff. The form was signed by nursing staff and dated 8/30/19. [Note: Resident 9's lisinopril was administered outside of the physician ordered parameters in August and September 2019. The Administrator documented that the problem was identified and addressed in August 2019.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and a record review it was determined, for 1 of 21 samples residents, that the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections. Specifically, licensed nursing staff did not sanitize scissors after dropping them on the floor, between the right and left foot, and during the change from a dirty to clean dressings on the lower extremities. Licensed nursing staff were observed to reach into the clean glove box with dirty gloves on. Licensed nursing staff were observed to clean wound by rubbing from a clean area to a dirty area and back to the clean area of the wound. Resident identifier: 23 Findings include: Resident 23 was admitted to the facility on [DATE] with a diagnosis of which included cellulitis of left lower and right lower limb, right and left foot with fat layer exposed, chronic kidney disease, hypothyroidism, and unspecific dementia. On 9/10/19 at 4:05 PM, it was observed that resident 23 had dressings on his bilateral lower extremities. The right lower extremity was observed to have a wound vac on the heel. At 4:06 PM, an observation was made of resident 23 receiving a dressing change to both feet by Registered Nurse (RN) 1 and Licensed Practical Nurse (LPN) 1. RN 1 was observed to bring in a zip lock bag with supplies. The zip lock bag was placed on the bed side table while RN 1 and LPN 1 placed a chux on the floor under resident 23's feet. RN 1 was observed to retrieve a handful of gloves. RN 1 was observed to put gloves on and touched the scissors which were observed to fall on the floor. RN 1 then picked up the scissors and proceeded to remove the soiled dressings on the left foot. No observation was made of RN 1 or LPN 1 sanitizing the scissors. LPN 1 helped remove the dressing from resident 23's left foot with gloves on her hands. The dressing was observed to be stuck to the back of resident 23's left leg and normal saline was used to remove the bandage. After removing the dressings RN 1 was observed to change gloves without washing his hands, applied new gloves, and processed with cleansing the wound per physicians order. While cleansing the left foot RN 1 cleansed the foot and lower leg and checked the wound vac dressing. No observation was made of RN 1 or LPN 1 sanitizing the scissors. RN 1 then picked up the scissors he used to remove the soiled dressings, cut the clean dressings, and applied the clean dressings to the wound. LPN 1 was not observed to change her gloves between the clean and dirty dressing changes nor wash her hands. On 9/10/19 at 4:20 PM, the Nurse Practitioner (NP) entered the room. RN 1 was observed to remove the dressing with the same scissors that had been observed to fall on the floor. The NP was observed to be told by RN 1 that resident 23 had a new yellow-white substance above the toes on his right foot. LPN 1 was observed to hold the right lower extremity using the same gloves that were used on the left foot dressing change. RN 1 asked LPN 1 to get more gloves from the box. LPN 1 was observed with gloved hands to reach into the glove box. LPN 1 was observed to hand the gloves to RN 1. LPN 1 was not observed to change her gloves during the dressing change or before putting her gloved hand into the box of gloves. On 9/10/19 at 4:27 PM, RN 1 changed gloves using the gloves that LPN 1 touched with her dirty gloves; No observation was made of RN 1 or LPN 1 sanitizing the scissors between the soiled dressings and the clean dressings on the right lower extremity. After removing the soiled dressing RN 1 proceeded to clean the wound on the right lower extremity. RN 1 was observed using an iodine swab on the clean part of the wound, moving to the yellowish-white substance found on the left part of the foot, and back to the clean part of the wound approximately three times with the iodine swab. RN 1 cut the clean dressing with the scissors that were not observed to be sanitized. RN 1 was observed to place the scissors next to the sink on the counter and left the room. On 9/11/19 at 1:36 PM, RN 1 was interviewed. RN 1 stated that he did not realize he had dropped the scissors on the floor. RN 1 stated that the scissors should have been cleaned after they fell on the floor. RN 1 stated scissors should also be cleaned when moving from a soiled area to a clean area and when moving from one area of the body to another. RN 1 further stated that he should have washed his hands between the right and left lower extremity. On 9/11/19 at 1:45 PM, the Minimum Data Set coordinator/Wound care Nurse was interviewed. The Wound Care Nurse stated that scissors should be cleaned with Santi cloth with bleach after touching the floor, when moving from a clean to dirty dressing, and when finished with the dressing change. The Wound Care Nurse stated that gloves should be changed when transitioning from dirty to clean and after direct contact with potentially infections body substances. The Wound Care Nurse stated gloves should be removed and hands washed when going from dirty to clean and changing wound sites. The Wound Care Nurse stated wounds should be cleaned from areas of clean to areas of infection and not back to the clean area. The Wound Care Nurse stated gloves should be removed before reaching into a glove box for new gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 21 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, residents with multiple falls did not have interventions revised on the care plan and a resident experiencing pain did not have his care plan implemented. Resident identifiers: 11, 22, and 23. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, severe protein calorie malnutrition, anxiety disorder, irritable bowel syndrome, muscle weakness, insomnia, and major depressive disorder. Resident 11's medical record was reviewed on 9/10/19. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 11 did not have a Brief Interview for Mental Status (BIMS) conducted. Resident 11 was assessed as rarely or never understood. In addition, the staff documented resident 11 required extensive assistance of one to two people for activities of daily living. A Fall Score form dated 6/22/19, revealed resident 11 had a score of 75. [Note: Morse Fall Scoring of 45 or higher categorizes resident 11 as high risk for falling.] [Note: A baseline care plan was not developed when resident 11 was admitted to the facility. A fall care plan was not developed for resident 11 until 7/6/19.] A review of the Progress Notes and Care Plans for resident 11 documented the following entries: a. On 6/23/19 at 12:32 AM, Bed in low position and call light within reach. b. On 6/23/19 at 8:43 PM, Resident was found by the Certified Nursing Assistant (CNA) sitting on the fall mat leaning against her bed. [Note: No new interventions were implemented.] c. On 7/6/19 at 4:26 PM, Resident was observed on the ground at 3:15 PM. Resident was previously taking a nap in her bed. The resident across the hall witnessed resident 11 roll out of bed. Blanchable redness was noted on her forehead. Bed was in lowest position, floor mats were in place, and the call light was within reach at the time of the fall. A Care Plan Focus dated 7/6/19 and revised on 9/4/19, documented The resident has had an actual fall 9/4/19 with no apparent injury r/t (related to) Poor Balance, Poor Communication/comprehension, unsteady gait, weakness. The goal developed was, The resident will resume usual activities without further incident through the review date. An intervention developed for 7/6/19 was, Post fall interventions: Bed in Lowest Position. Post fall interventions: Educate Resident. Post fall interventions: Educate Family. [Note: The intervention to have resident 11's bed in the lowest position was implemented on 6/23/19.] d. On 7/7/19 at 10:03 AM, Resident had call light within reach and reminded often how to use it. Resident was alert and oriented to self. [Note: Resident 11 was assessed with a BIMS score of 0 on 7/1/19. A resident that was severely impaired cognitively would have a BIMS score of 0 to 7.] e. On 7/9/19 at 10:08 PM, Resident had call light within reach, bed lowered to the lowest position, and any unwanted obstacles were removed from the room. [Note: An admission MDS assessment dated [DATE], documented that resident 11 required extensive assistance of one person for locomotion on and off the unit.] f. On 7/11/19 at 10:25 PM, Resident was sitting in the hallway by the nurses station. Resident had a jumpsuit on and had her arms inside her clothes. Resident was found lying on the floor in front of her wheelchair. Resident appeared to have slipped out of the wheelchair. A Care Plan intervention dated 7/11/19, documented Post fall interventions: Offer Snack/Drink. g. On 7/13/19 at 10:24 PM, Resident was on 72 hour charting for a recent fall. The resident was laying on the floor on the right side of the bed on her right shoulder. [Note: No new interventions were implemented.] h. On 7/16/19 at 9:25 PM, Resident had both of her hands in her clothing. It appeared that she was trying to get her arms free and she fell forward out of her chair in the living room. Resident reopened a skin tear on the right elbow. A Care Plan intervention dated 7/16/19, documented Post fall interventions: Clothing that is not too easily removed. i. On 7/28/19 at 11:13 PM, Licensed Practical Nurse (LPN) witnessed resident fall out of her wheelchair after attempting to undress out of her shirt. Resident fell forward landing on her left side. Resident hit the side of her head. Resident had a skin tear on her left elbow and abrasions and bruising to her forehead. [Note: No new interventions were implemented.] j. On 8/5/19 at 4:49 PM, Resident was observed on the floor in her room near the bed. Resident was laying on the floor mat and had blood coming from her head. The Registered Nurse (RN) assessed and the resident had a laceration on the top of her head. First aid given by staff and resident was transported to the emergency room (ER) for possible stitches. k. On 8/5/19 at 6:43 PM, Resident returned from the ER after getting staples to the laceration on her scalp from the fall this afternoon. The ER performed a computed tomography scan of the residents head and neck which showed no injuries. [Note: No new interventions were implemented.] l. On 8/17/19 at 4:36 AM, A CNA found the resident laying on her left side on the floor mat. Resident had a left elbow skin tear. The bleeding was controlled with direct pressure. [Note: No new interventions were implemented.] m. On 8/21/19 at 2:02 PM, Resident was observed on the floor on the side of her bed by the CNA. Resident was propping herself up on her right forearm. Residents forearm appeared red from pressure. A Care Plan intervention dated 8/22/19, documented Post fall interventions: Call light within Reach. [Note: The intervention to have resident 11's call light within reach was implemented on 6/23/19.] n. On 8/30/19 at 2:59 AM, Resident was found on the floor by her bed at 1:00 AM. Resident was face down. Resident has a new skin tear on her right elbow. [Note: No new interventions were implemented.] o. On 8/30/19 at 6:36 AM, Resident was found at 6:00 AM for the second time of the night. [Note: No new interventions were implemented.] p. On 9/4/19 at 9:59 AM, Resident tipped out of wheelchair at the nurses station today at 7:00 AM. Resident had a new skin tear to her left elbow and some redness to her forehead from bumping her head on a neighboring wheelchair. A Care Plan intervention dated 9/4/19, documented Provide activities that promote exercise and strength building where possible. Provide 1:1 (one on one) activities if bed bound. On 9/11/19 at 10:13 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that a baseline care plan was not initiated for resident 11. The MDS coordinator stated that the first care plan regarding falls was initiated on 7/6/19. The MDS coordinator stated that he would complete the comprehensive care plans for the residents. On 9/11/19 at 10:41 AM, an interview was conducted with CNA 1. CNA 1 stated that she would try and keep resident 11 up in her wheelchair throughout the day. CNA 1 stated that when resident 11 was in her bed she would roll out. CNA 1 stated that resident 11 was on two hour checks. CNA 1 stated that the two hour resident checks were not charted. CNA 1 stated that if a resident had a fall she would chart the resident checks every thirty minutes. CNA 1 stated that a fall mat was implemented for resident 11 after her first fall out of bed. CNA 1 could not recall if there were any interventions prior to resident 11's first fall. CNA 1 further stated that resident 11 required full assistance with ADLs and was only oriented to herself. CNA 1 stated that resident 11 was not able to ambulate on her own and required a wheelchair. On 9/11/19 at 11:08 AM, an interview was conducted with RN 2. RN 2 stated that there were no interventions in place to keep resident 11 safe from falls. RN 2 stated that resident 11 should be dressed in one piece outfits to keep her from removing her clothes. RN 2 stated that the staff would try and keep resident 11 where they could see her. RN 2 stated that the staff had tried to put resident 11 in the recliner in the dayroom but resident 11 did not want to stay in the recliner. RN 2 stated that the staff would try and keep resident 11 active throughout the day. RN 2 stated that resident 11 was stiff and would try to get up from her wheelchair on her own. RN 2 stated that the floor nurses would up date the resident care plans. RN 2 stated that the admission nurse would implement the baseline careplans. RN 2 further stated that resident 11 had a Call don't fall sign in her room, bed rails, a fall mat, and two hour checks to ensure that resident 11 was dry. RN 2 stated the Call don't fall sign was placed in a resident room on the wall where the resident was able to see the sign. RN 2 stated that the sign was a reminder for the resident to use their call light for assistance. On 9/11/19 at 11:18 AM, an observation was conducted of resident 11's room. Resident 11's room was observed with the Call don't fall sign on the wall and a floor mat was observed on each side of the bed. Resident 11's bed did not have side rails present and the bed was not in the lowest position. 2. Resident 22 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses which included fracture of left femur, atrial fibrillation, hypertension, displace fracture of greater trochanter of left femur, and congestive heart failure. Resident 22's medical record was reviewed on 9/10/19. A Quarterly MDS assessment dated [DATE], documented that resident 22 had a BIMS score of 5. [Note: A resident that was severely impaired cognitively would have a BIMS score of 0 to 7.] In addition, the staff documented resident 22 required limited assistance of one person for bed mobility, locomotion on the unit, toilet use, personal hygiene, and dressing. Resident 22 required extensive assistance of one person for transfers and locomotion off the unit. A Fall Score form dated 1/10/19, documented resident 22 with a score of 50. [Note: Morse Fall Scoring of 45 or higher categorizes resident 22 as high risk for falling.] A review of the Progress Notes and Care Plans for resident 22 documented the following entries: A Care Plan Focus dated 10/17/18, 5/29/19, and revised on 5/30/19, documented [Resident 22] is at high risk for falls r/t weakness, limited mobility, recent left femur fracture. The goal developed was, Resident to have no falls unreported to MD (Medical Doctor) during facility stay. Staff and resident to practice injury prevention measures for resident during facility stay. The resident will be free of falls through the review date. The interventions developed for 10/17/18, Anticipate and meet The resident's needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear such as shoes or non-skid socks when ambulating or mobilizing with w/c (wheelchair) or walker. Follow facility protocol. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. A Care Plan intervention dated 1/29/19, documented Post fall interventions: Educate Resident. Post fall interventions: Every 2-hour comfort/toilet rounds. A Care Plan intervention dated 2/28/19, documented 'Call don't Fall sign in room, bed in lowest position, and call light within reach. a. On 5/2/19 at 12:50 AM, Resident came out to the nurses station to get help with her bed. Walking back into her room the resident tried to open the curtain and got caught on it and fell on the left side of her body. Resident landed on her left hip. Resident was not able to bare any weight. Resident complained of pain. Resident did not want to go to the ER at that time. b. On 5/2/19 at 11:03 AM, A portable X-ray was ordered. Resident 22 had left hip arthoplasty with displacement of the acetabular component. Fracture of the greater trochanter of the left femur. The family has chosen to not proceed with surgical interventions. [Note: No new interventions were implemented.] c. On 5/15/19 at 3:53 AM, Resident 22 was found on the floor next to the bed sitting upright and yelling out. A Care Plan intervention dated 5/15/19, documented Post fall interventions: Every 1-hour comfort/toilet rounds. d. On 6/8/19 at 3:16 PM, RN heard resident yelling. Resident was observed sitting on the floor next to the bed. Resident was leaning on her right arm. Resident had a goose egg and bruising above her right eye, a skin tear on her right shin, and right elbow. A Care Plan intervention dated 6/8/19, documented Post fall interventions: Offer snack/drink. e. On 6/28/19 at 6:42 AM, Resident was found sitting on the floor next to the bed. Resident had a small skin tear on her left arm. [Note: No new interventions were implemented.] f. On 7/6/19 at 3:57 AM, The staff at the nurses station heard a noise of a wheelchair sliding. Resident was found on the floor next to her bed. [Note: No new interventions were implemented.] g. On 8/6/19 at 12:09 AM, Resident was heard from the nurses station calling for help. Resident was found near the bed on the floor laying on her left side. [Note: No new interventions were implemented.] h. On 8/13/19 at 3:47 PM, Resident was found calling for help. Resident was found next to her bed. [Note: No new interventions were implemented.] i. On 8/14/19 at 9:21 AM, Resident tried getting out of bed to go to the bathroom and slipped. A care plan intervention dated 8/14/19, documented Post fall interventions: Often used items within reach. j. On 8/22/19 at 3:10 AM, Resident was heard calling out for help from the nurses station. Resident was observed sitting on the floor next to the bed. Resident stated that she was transferring to her wheelchair and slipped out of bed. [Note: No new interventions were implemented.] k. On 9/2/19 at 1:19 PM, Resident was found at 9:15 AM. Resident was calling out and was observed on the floor next to the bed. Resident reported trying to go to the bathroom. A care plan intervention dated 9/2/19, documented Post fall interventions: Floor mats. [Note: The floor mat was documented in the incident report as being present during previous falls.] On 9/11/19 at 11:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the admitting nurse completed the baseline care plan within 24 to 48 hours of admission. The DON stated that the resident care plan would be addressed at all the interdisciplinary team meetings (IDTs). The DON stated that the resident family, caregiver, and the resident were included in the IDT meeting. The DON stated that the floor nurse would be responsible for implementing the care plan. The DON further stated that the floor nurse was responsible for revising the care plan and implementing interventions when necessary. The DON stated that himself and the Assistant Director of Nursing reviewed the care plans and education was provided to the staff when necessary. No additional information was provided regarding interventions to prevent falls for resident 11 or resident 22. On 9/11/19 at 1:04 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 22 was a one person assist with activities of daily living. CNA 1 stated that resident 22 tried to be independent. CNA 1 stated that resident 22 was oriented and able to make her needs known. CNA 1 stated that the staff took resident 22's walker away from her to help prevent falls. On 9/11/19 at 1:34 PM, an interview was conducted with RN 2. RN 2 stated that resident 22 used her call light if she required assistance. RN 2 stated that resident 22 would let staff assist her more. RN 2 stated that resident 22 had the floor mats in her room, the Call don't fall sign, and the staff checked on her every two hours. RN 2 stated that resident 22 was able to voice when she was needed to use the bathroom. RN 2 further stated that she would leave resident 22's blinds open during the day to help orient resident 22 to the time of day. 3. Resident 23 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower and right lower limb, right foot with fat layer exposed, left foot with fat layer exposed, chronic kidney disease, hypothyroidism, and unspecified dementia. On 9/10/19 at 9:36 AM, resident 23 was interviewed. Resident 23 stated that his feet hurt like a Son of a gun when staff changed the dressing. Resident 23 stated that medication did not touch the pain. On 9/10/19 at 3:05 PM, resident 23 was interviewed. Resident 23 stated that that his feet hurt. Resident 23 stated that he had to ask for pain medication but the medication did not work. Resident 23 stated it hurt like a son of a gun when the nurses changed the bandages on his feet. Resident 23 stated that he would like stronger pain medication before his feet are touched. Resident 23 stated that he did not always receive medication before bandage changes. Resident 23's feet were observed to be covered with his toes exposed. Resident 23 toes were observed swollen and the toe nails were pulling up from the skin. The area between resident 23's toes was observed to be a blackish yellow with open wounds between the toes. There was some cotton observed between the toes. Resident 23's medical record was reviewed on 9/10/19. A care plan dated 8/13/19 revealed, [Resident 23] has potential for alteration in comfort r/t chronic ulcers of lower extremities, current infection, limited mobility. Some of the goals developed were, The resident will not have discomfort related to side effects of analgesia through the review date. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions developed were: 1. Administer analgesia as per MD orders. 2. Monitor/document for side effects of pain medication. 3. Monitor/record/report to Nurse and s/s (signs and symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). 4. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. 5. Identify, record and treat the resident's existing conditions which may increase pain and or discomfort. 6. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. 7. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. On 9/10/19 at 4:06 PM, an observation was made of resident 23. Resident 23 was observed in his wheelchair in his room. RN 1 was observed to enter resident 23's room with LPN 1. RN 1 was observed to kneel on the ground in front of resident 23. LPN 1 was observed to kneel to the left side of resident 23. RN 1 stated to the surveyor as he started to cut off the dressing on the left foot that, it's quiet painful for him. Resident 23 was observed throughout the dressing change grimacing, putting his shoulders by his ears, taking deep breathes, closing his eyes, flinching and pulling his foot away. During the observation of the dressing change resident 23 stated his pain was at an 8. RN 1 was observed to offer resident 23 pain medication when the dressing change was over and resident 23 stated Nah. On 9/10/19 at 5:00 PM, RN 1 was interviewed. RN 1 stated that he had just talked to wound nurse about resident 23's pain. RN 1 stated that the facility recently hired a new set of physician's. RN 1 stated that he did not feel that the gabapentin helped with the pain during the dressing change and when resident 23 went to the wound clinic. RN 1 stated that the wound nurse told him that he was going to contact MD 1 regarding pain. RN 1 stated that MD 2 was contacted and he increased resident 23's gabapentin. RN 1 stated that the Nurse Practitioner asked for facility staff to contact MD 1 in regards to pain medication orders. RN 1 stated that resident 23 usually stated that he was okay during a dressing change but noticed his eyes were big and his body was stiff which demonstrated pain. On 9/11/19 at 7:19 AM, the Wound Nurse (WN) was interviewed. The WN stated that he talked to the wound care physician and the wound care physician told him he would send over an order for pain medication to administer before resident 23's wound care appointment. The WN stated that MD 1 ordered an increase in the gabapentin. The WN stated that was the first time he had contacted a physician regarding resident 23's pain. On 9/11/19 at 10:05 AM, an interview was conducted with MD 1. MD 1 stated that his first day in the facility was 9/5/19. MD 1 stated that he was notified of resident 23's pain for the first time on 9/5/19. MD 1 stated he talked with a nurse at the facility about resident 23's pain. MD 1 stated that he assessed resident 23's pain and resident 23 described pain that was more consistent with neuropathy. MD 1 stated that resident 23 described his pain as pins and needles. MD 1 stated that he increased resident 23's gabapentin to alleviate the pain. MD 1 stated that, I understand they (facility staff) were trying to control his pain and balance his pain with also not sedating him. MD 1 stated that he was unaware that resident 23 was experiencing pain during dressing changes and would have looked into that a little more and addressed that pain. On 9/11/19 at 10:13 AM, the DON was interviewed. The DON stated that he had not been notified that resident 23 was having pain during wound dressing changes. The DON stated that resident 23's pain during dressing changes should be directly communicated to the physician. The DON stated the nurses should call the physician or use the communication form to notify the physician regarding a resident's pain. On 9/11/19 at 10:41 AM, the DON was re-interviewed. The DON stated that he was unable to provide information that the physician was notified of pain prior to 9/2/19. The DON stated that the physician prior to 9/1/19 had not addressed resident 23's chronic pain.