**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing a resident's assessment. Specifically, for 1 out of 58 sampled residents, the facility did not transmit a resident's completed discharge MDS assessment to CMS. Resident identifier: 57. Findings included: Resident 57 was admitted to the facility on [DATE] and discharged on 1/19/24 with diagnoses of polyosteoarthritis, pain in left hip, carpal tunnel syndrome bilateral upper limbs, cerebral infarction due to embolism of left middle cerebral artery, essential hypertension, noninfective gastroenteritis and colitis, major depressive disorder, insomnia, ischemic optic neuropathy right eye, and ischemic optic neuropathy left eye. Resident 57's medical record was reviewed from 6/3/24 through 6/11/24. A discharge MDS assessment was completed on 1/31/24. Question A0140 of the assessment had the response, Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State, The assessment submission information stated, Do not submit to CMS. On 6/5/24 at 2:11 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the discharge MDS assessment for resident 57 had been completed, but it had not been transmitted to CMS because she had marked that the facility did not have Medicare or Medicaid certified beds on question A0410 of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, 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, for 1 out of 58 sampled residents, a resident's antihypertensive medication was not held when the diastolic blood pressure (DBP) was below the physician's ordered parameters. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease without dyskinesia without mention of fluctuations, major depressive disorder, generalized anxiety disorder, dementia, chronic pain, and essential hypertension. Resident 8's medical record was reviewed on 6/6/24. On 4/28/23, a physician's order documented dilTIAZem HCl [hydrochloride] ER [extended release] Oral Tablet Extended Release 24 Hour (Diltiazem HCl) Give 240 mg [milligrams] by mouth one time a day for Hold for SPB [sic] [systolic blood pressure] < [less than] 120, DBP < 80, or P [pulse] < 60 related to ESSENTIAL (PRIMARY) HYPERTENSION. A review of the May and June 2024 Medication Administration Record documented when the DBP was less than 80 and the diltiazem was administered to resident 8 when it should have been held according to the physician's order. a. On 5/2/24, 162/77 b. On 5/10/24, 151/78 c. On 5/14/24, 130/77 d. On 5/15/24, 135/79 e. On 5/16/24, 134/66 f. On 5/20/24, 128/74 g. On 5/23/24, 134/76 h. On 5/25/24, 131/77 i. On 5/27/24, 153/76 j. On 5/28/24, 160/64 k. On 5/31/24,142/78 l. On 6/1/24, 136/76 m. On 6/3/24, 130/76 n. On 6/4/24, 132/76 o. On 6/5/24, 130/77 p. On 6/6/24, 116/74 On 6/10/24 at 10:50 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 reviewed the diltiazem physician's order and stated that she was unsure how the physician's order was wrote and she would need to get clarification. On 6/10/24 at 12:28 PM, an interview was conducted with RN 2. RN 2 reviewed the diltiazem physician's order and stated that yes if any of the parameters were below what was specified then the medication should be held. RN 2 stated that the floor nurses would input the physician's orders or sometimes the Director of Nursing (DON) or the Assistant Director of Nursing would help. On 6/10/24 at 12:39 PM, an interview was conducted with the DON. The DON reviewed the diltiazem physician's order and stated that yes it should be held when any of those parameters were outside of what the physician had ordered. The DON stated it was usually to hold with the systolic blood pressure was below the physician's ordered parameters. The DON stated that she would check with the doctor. On 6/10/24 at 12:53 PM, a follow up interview was conducted with the DON. The DON stated the doctor had changed the physician's order because resident 8 usually ran in the 70's anyway's. The DON stated that the doctor changed the physician's order to hold if the DBP was below 90.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 58 sampled residents, a resident taking an antidepressant medication for insomnia had not received a GDR on that medication since 2022, and the medication was not clinically contraindicated. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, cerebral infarction due to embolism, nontraumatic subarachnoid hemorrhage, spastic hemiplegia affecting left nondominant side, pseudobulbar affect, dysphagia, aphasia, major depressive disorder, insomnia, hypotension, and cognitive communication deficit. Resident 23's medical record was reviewed on 6/6/24. On 5/20/22, a physician's order documented traZODone HCl [hydrochloride] Tablet Give 50 mg [milligrams] by mouth at bedtime for insomia [sic]. The physician's order was discontinued on 7/13/22. On 7/14/22, a physician's order documented traZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED. A physician documented clinical contraindication was unable to be located. On 3/28/24, a Nurses Note documented Note Text : IDT [Interdisciplinary Team] psychotropic review. Reviewing abilify, bupropion and trazodone. Tracking in place. Consent in place. Defer to [behavioral health name redacted.] [Note: The progress notes were reviewed from June 2023 to current. This Nurses Note was the only psychotropic review note able to be located.] On 6/11/24 at 10:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the psychotropic meetings were held monthly and a note was made. The DON stated that the Pharmacist consultant attended the psychotropic meetings. The DON stated she would do a piece of the alphabet and new admissions so residents did not get missed. The DON stated she would look at the residents who were in the window for a GDR, look at the alert charting to see if the resident had failed a GDR, and looked at where the residents were at with their medications. The DON stated they had tracking in place for behaviors, we make sure the medications had the right diagnosis, and look at the resident's Preadmission Screening and Resident Review level 2. The DON stated that not having a GDR of the trazodone probably had something to do with resident 23's spouse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 58 sampled residents, a resident had a basic metabolic panel (BMP) collected on two occasions without a physician's order. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affection right dominant side, type 2 diabetes mellitus, dementia, altered mental status, atrial fibrillation, cognitive communication deficit, protein-calorie malnutrition, dysphagia, major depressive disorder, anxiety disorder, and essential hypertension. Resident 12's medical record was reviewed on 6/10/24. A physician's order with a start date of 5/15/24, documented BMP to be drawn three times weekly on Monday Wednesday and Friday, Noc [night] shift to print order and put it in the lab book. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. The physician's order was discontinued on 6/2/24. On 6/3/24, a Lab Results Report documented that a BMP was collected and completed. No documentation could be located or provided to indicate a physician's order was written for the lab collected on 6/3/24. On 6/4/24 at 1:00 AM, an encounter documented by the Medical Director (MD) documented . Chief Complaint / Nature of Presenting Problem: Lab results review Hypernatremia Hypokalemia Hyperchloremia History Of Present Illness: . We will recheck pt [patient] BMP again in 2 days. Follow-up Plan: . We will recheck pt BMP again in 2 days. On 6/4/24 at 5:30 PM, a Nurses Note documented Note Text: New orders to increase tube feed freewater by 20mL/hr [milliliters per hour] to treat hypernatremia, recheck BMP in 3 days on 6/7/24, and to increase AM Lantus dose to 13 units r/t [related to] high blood sugars. Orders placed in PCC [electronic medical record system], copy of order placed in lab book, and amount of water flush changed on feeding machine. On 6/4/24 at 8:15 PM, an Alert Charting Note documented Reason for alert charting : med [medication] changes Interventions: AM Lantus increased to 13U [units]; increase water flush with his enteral feeding to 80ml/hr r/t DX [diagnosis] of hypernatremia; BMP to be drawn in 3 days (6/7/24) . On 6/5/24, a Lab Results Report documented that a BMP was collected and completed. No documentation could be located or provided to indicate a physician's order was written for the lab collected on 6/5/24. A physician's order with a start date of 6/7/24, documented Check BMP on 6/7/24 one time only for 1 Day. A physician's order with a start date of 6/10/24, documented BMP to be drawn weekly on mondays. one time a day every Mon for labs. The physician's order was created on 6/3/24. On 6/10/24 at 3:09 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when she got a lab order she would put it into the computer, print the face sheet and lab order, and put the face sheet and lab order in the lab book on the date to be drawn. RN 1 stated if the lab was not an urgent lab the lab came every Monday, Wednesday, and Friday. RN 1 stated that urgent labs were drawn in house and the lab would come pick them up. RN 1 stated there was a lab tracking sheet in the front of the lab book and the nurse communication book. RN 1 stated that she would update the resident's family with everything. RN 1 stated that she would inform the resident's family before the lab was drawn, why the lab was being drawn, and the results of the lab. On 6/10/24 at 3:15 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that first thing in the morning should would check the labs. The ADON stated the outside lab company had an on-line service that she was able to review. The ADON stated that when the lab was ordered she would write it down and make sure it got done. The ADON stated if the lab was an ongoing lab she would track the lab. The ADON stated she would pull and print the lab orders for the lab book. The ADON stated she would check the results screen, any unmatched labs were matched to the residents, and she would make sure the MD signed the labs. The ADON stated that urgent labs were draw by the staff and the labs would be sent with the courier. The ADON stated that the courier was usually at the facility within an hour. The ADON stated that results with urgent labs were fairly quickly, same day, and the lab would fax the results to the facility. The ADON stated that sometimes the MD would give verbal orders and those were hard to track.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, several surfaces that came into contact with food or food preparation utensils were found to be dirty, staff were observed to not practice hand hygiene, food was exposed to open air, and there were several instances of potential physical food contaminants. Findings included: On 6/5/24, an inspection of the facility kitchen was conducted. On 6/5/24 at 11:26 AM, an observation was made of a metal rack used to store clean meal trays after they were sent through the dishwasher. There was metal plating surrounding the metal rack. The metal plating was noted to be rusty. There was a meal tray touching the rusty surface. There was also a small red bug crawling on the metal rack. On 6/5/24 at 11:29 AM, an observation was made of a vent blowing air from the ceiling. The vent was noted to be covered in a thick layer of dust. On 6/5/24 at 11:34 AM, an observation was made of a metal storage cart used to store clean baking sheets. The racks of the cart were noted to be dirty and covered in food crumbs. The dirty racks were in contact with the baking sheets. On 6/5/24 at 11:52 AM, an observation was made of a container of coffee grounds. The container of coffee grounds did not have a lid on it and was open to the air. The coffee grounds were not actively in use. On 6/5/24 at 12:14 PM, an observation was made of the lunch tray line. Dietary Aide (DA) 1 was observed grabbing their cell phone out of their pocket and looked at the phone screen. DA 1 put the phone back in their pocket. DA 1 then wrote in permanent marker on the saran wrap covering a hotel pan full of chicken noodle soup. DA 1 then opened the walk-in fridge and placed the soup in the fridge. DA 1 then wiped their right arm across their forehead. DA 1 then touched a cup of hot chocolate. DA 1 dumped out the hot chocolate and opened a new packet of hot chocolate powder and poured it into the cup. DA 1 then took a cart full of meal trays from the kitchen to the hallway. DA 1 was not observed to wash their hands during the series of events. On 6/5/24 at 12:17 PM, an observation was made of a stack of clean plates on a drying rack. The plate on top of the stack of dishes was noted to still have food debris on it. On 6/5/24 at 12:18 PM, an observation was made of the ceiling above food preparation areas. The ceiling was noted to have food debris and stains. On 6/5/24 at 1:48 PM, an interview was conducted with the Assistant Dietary Manager (ADM). The ADM stated that there is a cleaning schedule for the kitchen. The ADM stated that the kitchen should be cleaned daily. On 6/6/24 at 3:02 PM, an additional interview was conducted with the ADM. The ADM stated that the kitchen staff were actually responsible for cleaning the vents in the kitchen, not maintenance. The ADM stated that the vents were not on the kitchen cleaning list, but they had been added and that she had stayed late the previous night to clean the vents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined for 1 of 7 sample residents, that the facility did not ensure a therapeutic diet was offered when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, a resident was not provided a fortified/enhanced diet. Resident identifiers: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mycobacterial infections, human immunodeficiency disease (HIV), localized edema, anemia, immune reconstitution syndrome, severe protein calorie malnutrition, hypotension, ascites, splenomegaly and pleural effusion. Resident 4's medical record was reviewed on 1/2/24. On 1/2/24 at 10:15 AM, an observation was made of resident 4 lying in bed with his tube feeding infusing. Resident 4 refused the interview even with translation offered. Resident 4's physician orders revealed a physician's order dated 11/28/23 for a Fortified/enhanced diet, regular texture, with thin consistency. An admission Nutritional assessment dated [DATE] documented, [Resident 4] needed a fortified/enhanced regular diet. Resident 4's care plan was initiated on 12/5/23 and updated on 12/14/23 revealed, [Resident 4] had potential for or presence of altered nutrition needs. Nutritional risk factor: Need of AN (additional nutritional) support r/t (related to) DX (diagnoses) of HIV. Interventions in place were; Diet per order and observe for signs of malnutrition. The goal developed was, [Resident 4] will receive food of appropriate texture. Will be pleased with meal service and food choices. On 1/2/24 at 10:28 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 4 was able to eat every meal despite having a feeding tube. RN 1 stated the resident just needed assistance sitting up on the edge of his bed. RN 1 stated resident 4 preferred Vietnamese food and RN 1 would occasionally bring it in for resident 4. RN 1 stated resident 4 was very thin and did have extra calories put into his meals. On 1/2/24 at 1:05 PM, an observation was made of a lunch tray taken to resident 4. The tray had a glass of apple juice, mashed potatoes and gravy, two breaded chicken strips with one cut into pieces, and a roll. The meal ticket on the tray for resident 4 documented the meal as regular enhanced. On 1/2/24 at 1:15 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 4 would eat the meals the meals that were brought in to him but he did not eat all the food that was offered. CNA 1 stated resident 4 was on a fortified diet since he was very thin. At 12:35 PM, an interview was conducted with the Head [NAME] (HC). The HC stated the meal ticket had what type of diet a resident needed. The HC stated the enhanced diet had a hot cereal with milk, butter and brown sugar for breakfast. The HC stated sometimes the soups at lunch and dinner were enhanced. The HC stated there was no item that was enhanced for lunch. On 1/2/24 at 2:55 PM, an interview was conducted with the Registered Dietician (RD). The RD stated with an enhanced diet the residents would receive super cereal for breakfast and whole milk with each meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility did not have detergent for the dish machine, there was cardboard duct taped to the hood vent, refrigerators at the nurses stations were soiled and there were soiled areas in the kitchen. Findings include: 1. On 1/2/24 at 9:49 AM, a dirty meal tray was observed at the bottom of the ice and water cart in the hallway outside room [ROOM NUMBER]. 2. On 1/2/24 at 10:00 AM, an observation was made of the facility dish machine. There were 3 tubes coming from the dish machine. One tube was in a bucket labeled Ultra San, another labeled Rinse Aide and a third labeled Dish Machine Detergent. The Ultra San was a liquid sanitizer. The detergent was observed to be a clear color. The dish machine was observed to have 50 parts per million of chloride bleach. An interview was conducted with Dietary Aide (DA) 1. DA 1 stated the dish machine needed to have a temperature above 140 degrees Fahrenheit. DA 1 stated the dish machine used sanitizer. DA 1 was observed to check the sanitizer solution. The chloride bleach strip turned to a dull purple color which was 50 parts per million. An interview was conducted with the Head [NAME] (HC). The HC stated the facility had not ran out of sanitizer and detergent. The HC stated the new Dietary Manager (DM) was watching to see how much detergent and sanitizer was used to know when to order. On 1/2/24 at 2:25 PM, an observation was made of the dish machine with the DM. DA 1 and DA 2 were observed to be putting dishes away from the dish machine. The DM was observed to look at the dish machine chemicals. There were 3 tubes from the dish machine into solutions. There was one tube that went to Ultra San, another to the Quarts Sanitizer, and another to a rinse agent. There was a container labeled Dish Machine Detergent that was a clear substance. There was no tube to the dish machine into the detergent. The DM stated the container was water that dripped from the dish machine because the disposal did not work. The DM then stated the the clear liquid was 1 part bleach and 4 parts water because the facility had ran out of dishwashing detergent. The DM stated the facility ran out of dish machine detergent on 1/1/24 and he had mixed the bleach mixture. The DM stated the clear liquid was bleach, water and the remaining about of dish detergent. The DM stated he was instructed to mix the solution by a corporate staff member. The DM stated he was unable to remember who the staff member was. 3. On 1/2/24 at 10:00 AM, an observation was made of the kitchen. The following observations were made: a. The steam table in the dining room was observed to be soiled on the plastic glass. Underneath the shelf above the food basins on the steam table were observed to be soiled. b. In the walk in refrigerator there were 10 chocolate mighty shakes in a container. There were no dates on the mighty shakes or on the container. The label revealed Store Frozen .Used thawed within 14 days. c. The front of oven had a dried liquid substance on the front of it. d. There was food splatter on the ceiling above the trayline in the dining room. 4. On 1/2/24 at 10:30 AM, the resident snack refrigerator at the North hall nurse's station was observed. There was a chocolate frosty in the door with no date and was thawed. There was an orange substance spilled on the shelves. 5. On 1/2/24 at 10:35 AM, the resident snack refrigerator at the South Hall nurse's station was observed. There was a large green substance in the bottom of the refrigerator. There were grocery sacks with no dates or labels. There was a pizza box with no date. There was an espresso cold drink opened and covered with a glove with no date. At 10:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they were not sure who was responsible for cleaning the refrigerators at the nurses station. LPN 1 stated they were not sure how long the refrigerator had been dirty or why the items were not labeled or dated. LPN 1 stated It's kind of gross. On 1/2/24 at 2:14 PM, an interview was conducted with the DM. The DM stated he did not know why there was cardboard duct taped to the hood vent. The DM stated the facility needed the hood vent replaced. The DM stated the fans were really loud. The DM stated he was not aware that there were refrigerators at the nurses station. The DM stated the Administrator talked to him about the dietary staff cleaning the refrigerators and checking their temperatures. On 1/2/24 at 2:15 PM, an interview was conducted with the HC. The HC stated the cardboard was because the vent blew cold air onto the staff members. The HC stated the mighty shakes should have been dated. The HC asked DA 2 when the mighty shakes were pulled from the freezer. The HC stated DA 2 stated to him the mighty shakes were pulled from the freezer on 12/30/23. On 1/2/24 at 2:44 PM, an interview was conducted with the facility Registered Dietitian (RD). The RD stated she was at the facility 1 to 2 times per week and completed a monthly kitchen audit. The RD stated she was newly employed by the facility and was looking at completing some quality improvement. The RD stated she had been walking through the kitchen with the new DM. The RD stated in her first report, there were concerns with the facility dish machine. The RD stated the booster breaker was turning off and staff had to watch the water temperatures for all dish machine cycles. The RD stated there was detergent, rinse aide and sanitizer when she completed her audit. The RD stated the dish machine should have detergent and sanitizer instead of 2 sanitizers. On 1/2/24 at 3:28 PM, an interview was conducted with the Administrator. The Administrator stated the DM had been talking with the company that supplied the chemicals for the dish machine. The Administrator stated he was not aware that the facility did not have dish washing detergent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not develop and implement a comprehensive person-center care plan for 1 of 35 sampled residents, 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, a resident did not have a care plan to attain or maintain the highest practicable physical, mental and psychosocial well-being when receiving psychotropic medications. Resident Identifier: 62 Finding include: Resident 62 was initially admitted on [DATE] and again on 2/21/22 with diagnoses that included low back pain, Parkinson's disease, bipolar II disorder, generalized anxiety disorder and cognitive communication deficit. On 3/15/22, Resident 62's medical record was reviewed. Resident 62's 12/19/21 Admitting Minimum Data Set (MDS) revealed he had an active diagnoses of an anxiety disorder, depression and schizophrenia and was receiving antipsychotic medications. Resident 62's Care Plan was updated on 3/15/22 with a new Focus, which read, Scott has Potential for complications r/t (related to) Psychotropic medication use for depression with insomnia, anxiety This Focus area included a Goal and multiple Interventions, which were also initiated on 3/15/22. Note: This new Focus area in resident 62's Care Plan was added two days after starting the Recertification Survey on 3/13/22. On 3/15/22 at 12:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1 and Registered Nurse (RN) 2. The two nurses stated that they initiate a Care Plan when a resident is first admitted . They stated that a skin check is performed, and the resident is asked about their health care issues. RN 2 stated that when a resident has orders for psychotropic medications, she has the resident or the resident's representative sign a consent to receive the psychotropic medications and then adds a Focus area for the psychotropic medications in the resident's Care Plan. On 3/15/22 at 1:01 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that if a resident had received an order for psychotropic medication that it should have been reviewed in their morning meetings and should have been added to the resident's Care Plan within a day or two after the medication order was received. Resident 62's psychotropic medications were ordered on 2/22/22 and 2/24/22, but a Focus area for receiving psychotropic medication was not added to his Care Plan until 3/15/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included rheumatoid arthritis, spinal fusion, paraplegia, urinary tract infection, major depressive disorder, and neuropathy. On 3/14/22, resident 6 was interviewed and stated she was lucky to shower two times a week but only got 1 shower last week. They used to have a shower aide to do the showers now it was just the certified nursing assistants (CNA's). Resident 6 stated she would like to shower 3 times a week and that she has made the staff aware of this. On 3/15/22, resident 6's medical record was reviewed. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 6 was totally dependent with 2 person physical assist for bathing. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 6 resided in room [ROOM NUMBER]-B and was in the column to shower on Mon, Wed, Fri in the morning. A Care Plan dated 12/6/21 revealed the resident had a potential for self care deficit related to pain, weakness and neurogenic bladder with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. Certified Nursing Assistant (CNA) documentation for showers in the tasks section of resident 6's medical record revealed showers from 12/2/21 until 3/14/22. Resident 6 went 7 days without a shower from 12/13/21 until 12/20/21 and 12/20/21 until 12/27/21. In January, resident 6 went without a shower from 12/30/21 until 1/12/22, which was 13 days. And from 1/21/22 until 1/28/22, which was 7 days. In February, resident 6 went without a shower from 1/28/22 until 2/4/22 and 2/22/22 until 2/28/22. And in March, resident 6 went without a shower from 2/28/22 until 3/7/22. 3. Resident 22 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, hemiplegia of the right side, epilepsy, blindness of the right eye, major depressive disorder, dysphagia, and need for assistance with personal care. On 3/13/22 at 2:08 PM, an interview was conducted with resident 22. Resident 22 stated she would like to have more showers. Resident 22 stated she would like a shower every other day but usually only got them twice a week if that often. They are bad at giving us showers. On 3/15/22, resident 22's medical record was reviewed. An Annual MDS dated [DATE] revealed resident 22 required substantial maximal assist with bathing. A Care Plan dated 12/20/19 revealed the resident had a potential for self care deficit related to traumatic brain injury, weakness and blindness with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. The form titled Showers revealed resident 22 was to be showered on Monday, Wednesday, and Friday according to the location of her room. Certified Nursing Assistant (CNA) documentation for showers in the tasks section of resident 22's medical record revealed showers from 12/2/21 until 3/14/22. Resident 22 went 7 days without a shower from 12/13/21 until 12/20/21. In January, resident 22 went 5 days without a shower from 1/5/22 until 1/10/22. In March it was noted resident 2 received showers twice a week. 4. Resident 48 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included amputated stump, morbid obesity, type II diabetes, mild cognitive impairment, and mild intellectual disabilities. On 3/13/22 at 1:54 PM, an interview was conducted with resident 48. Resident 48 stated he did not get to bathe when he would like to, which was 3 times a week. He stated he only got to bathe 1 time a week and sometimes none. Resident 48 stated it had been like this for a while because the facility was low on staff. On 3/15/22, resident 48's medical record was reviewed. A Care Plan dated 11/1/21 revealed the resident had a potential for self care deficit related to incontinence, pain weakness and developmental delay with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. The form titled Showers revealed resident 48 was to be showered on Monday, Wednesday, and Friday according to the location of his room. Certified Nursing Assistant (CNA) documentation for showers in the tasks section of resident 22's medical record revealed showers from 12/2/21 until 3/14/22. Resident 48 went without a shower from 2/21/22 until 2/28/22. And 3/9/22 until 3/16/22, which was 7 days. On 3/15/22 at 12:00 PM, an interview was conducted with CNA 2. CNA 2 stated showers are done according to the shower schedule on the form at the nurses' desk. CNA 2 stated they try hard to get everyone's showers completed, but it can get difficult. On 3/16/22 at 12:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated it was company policy to ask the residents to shower but we cannot force them. It was expected of the staff to assist residents to shower if they would like, the residents tell us their shower preference on admit. The DON stated the 90 percent of the time we have enough CNAs to get the showers done, but weekends have been hard. Most showers are done during the week. Based on interview and record review it was determined that the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, for 4 out of 35 sampled resident, residents that were dependent on ADLs did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifiers: 6, 16, 22, and 48. Findings included: 1. Resident 16 was admitted to the facility initially on 7/10/2020 and was re-admitted on [DATE] with diagnoses that included rheumatoid arthritis, polyneuropathy, Sjogren syndrome, chronic osteomyelitis, cellulitis, protein-calorie malnutrition, muscle weakness, sacral ulcers stage 3 and 4, neuromuscular scoliosis, hypo-osmolality and hyponatremia. On 3/13/22 at 2:54 PM, an interview was conducted with resident 16. Resident 16 stated she would like to get a shower at least once per week. Resident 16 stated she had a bath 3 days ago, however, she stated her baths were not consistent. On 3/15/22 at 11:24 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated resident 16's shower days were on Tuesday, Thursday, and Saturday in the evenings. CNA 2 stated when resident 16 went to the toilet the staff would wipe her down. CNA 2 stated if resident 16 does not turn her call light on the staff would go ask when she wanted a shower. CNA 2 stated resident 16 had refused some showers. CNA 2 stated if resident 16 refused a shower the policy was that the CNA would tell the nurse on duty and the nurse would have to sign the refusal. CNA 2 stated during rounds the staff coming on shift would be told that the resident had missed or refused a shower and the CNAs would try the next day. CNA 2 stated when the facility is short staffed, they do the best they can. CNA 2 stated that during the day if staff were unable to get to all the showers, they would move those showers to the PM (evening) shift, or sometimes showers would be done on Sundays. CNA 2 stated if help was needed, additional staff members would be called in to help with showers. On 3/16/22 resident 16's electronic medical record (EMR) was reviewed, including shower sheets provided by the facility. Resident 16's most recent Minimum Data Set (MDS) was reviewed and revealed that (Section F) resident 16 felt it was very important to choose between a bath, shower, bed bath or sponge bath, (Section G) resident 16 needed extensive 1 person assistance with hygiene, and (Section GG) resident 16 required maximum assistance with showers. Resident 16's shower task was reviewed for the previous 4 months. For the month of March, as of the 14th day, resident 16's shower sheet did not document any showers. For the month of February, showers were documented on 2/4/22, 2/7/22, 2/11/22, 2/18/22 (7-day gap), 2/25/22 (7-day gap that included a refusal on 2/21). Resident 16 received 5 showers in the month of February. In January, resident 16 received a shower on 1/3/22, 1/12/22 (a 9-day gap with 1 refusal on 1/10), 1/24/22 (a 12-day gap with refusals on 1/14, 1/17, and 1/21). Resident 16 refused showers on 1/28 and 1/31 and received no other showers the remainder of the month. Resident 16 received a total of 3 showers in the month of January.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined 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, for 1 out of 35 sampled residents, the facility administered hypertensive medications when the blood pressure measurements were outside of the physician ordered parameters and administered insulin outside of physician ordered parameters. Resident identifier: 37 Findings included: Resident 37 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included right hip osteoarthritis, ventricular fibrillation, cardiomyopathy, congestive heart failure, hypertension, and type II diabetes. On 3/15/22, resident 37's medical record was reviewed. A Physician's order dated 11/30/21, documented a medication order for Carvedilol tablet 12.5 mg (milligram) by mouth twice a day for hypertension, hold for B/P (blood pressure) less than 110/60 mm Hg (millimeters of mercury). And a Physician's order dated 12/1/21, documented a medication order for Lisinopril tablet 20 mg by mouth once a day for hypertension, hold for B/P less than 110/60 mm Hg. A review of the January and March 2022 Medication Administration Record (MAR) documented the following entries when resident 37's vital signs were below the physician ordered parameters and the Carvedilol and Lisinopril were administered: a. On 1/30/21, B/P 95/51 b. On 3/6/21, B/P 104/57 c. On 3/7/21, B/P 102/50 A Physician's order dated 1/20/22, documented a medication order to administer Humalog Insulin by injecting 5 units subcutaneously before meals, hold for blood glucose (BG) less than 140. A review of the January 2022 Medication Administration Record (MAR) documented the following entries when resident 37's blood glucose levels were below the physician ordered parameters and the Humalog Insulin was administered: a. On 1/22/21 at 12:03 PM, BG 125 b. On 1/22/21 at 4:45 PM, BG 133 On 3/15/22 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated when passing medications, the doctors' orders should always be followed. The orders and parameters are in the MAR and you can see them when you are passing out medications. On 3/16/22 at 11:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses should check the MAR when passing medications to residents. The orders that are given from the doctor would be in the MAR and each nurse can find them, if there was a question they should check with the doctor before giving the medication. It was expected that the nurses will follow the orders given by the physician.

Based on observation and interview, it was determined that the facility did not store food in accordance with professional standards of food service safety. Specifically, food in the freeze and refrigerator was not sealed and was open to air. Findings include: On 3/13/22 at 10:15 AM, an initial tour of the kitchen was conducted. The following item was observed to be unsealed and open to air: 1. In the refrigerator: an unsealed box of beef patties. On 3/16/22 at 10:58 AM, a second walk-through of the kitchen was conducted. The following items were observed to be unsealed and open to air: 1. In the refrigerator: an unsealed box of pre-made omelets. 2. In the dry-storage room freezer: an unsealed box of Salisbury steak patties. On 3/16/22 at 11:00 AM, an interview was conducted with the facility Dietary Manager (DM). The DM accompanied the surveyor on the second walk-through of the dry storage area. The box of Salisbury steak patties was brought to the attention of the DM. The DM stated she had educated her staff about sealing food in the refrigerator and freezer and would need to re-educate the staff to ensure food items were sealed when stored.

Based on interview and record review the facility did not maintain a quality assessment and assurance (QAA) committee consisting of the required members. Specifically, the QAA Committee was held five times in 2021, however the medical director only attended one of those meetings. Findings include: On 3/16/22 at 12:29 PM, an interview and review of the QAA Committee meetings' attendance logs were conducted with the facility's administrator. Review of the QAA Committee meetings in 2021 revealed the committee met on 3/11/21, 4/2/21, 5/12/21, 8/27/21 and 12/27/21. Review of the attendance logs for the 2021 QAA Committee meetings revealed that the medical director attended only the 12/27/21 meeting. The administrator confirmed that the medical director attended only the one meeting in 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not follow the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines to offer pneumococcal immunizations for 1 of 35 sampled residents. Specifically, a current resident, who had resided in the facility since June 2017 was not offered the 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) per CDC and ACIP guidelines. Resident Identifier: 50 Findings include: Resident 50 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (stroke), hemiplegia or hemiparesis, gastroesophageal reflux disease, hyperlipidemia, thyroid disorder, osteoporosis, malnutrition, anxiety disorder, and depression. On 3/12/22, Resident 50's medical record was reviewed. Resident 50's immunization history revealed that she was offered but refused the 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) on 6/2/17. There was no documentation that the PPSV23, Pneumovax23 vaccine was offered, refused, or received. On 03/16/22 at 10:25 AM, an interview was conducted with the facility's Assistant Director of Nursing/Infection Preventionist ADON/IP. The ADON confirmed that there was no documentation that resident 50 was offered the PPSV23, Pneumovax23 vaccine. The ADON/IP stated she had just started working at the facility in December 2021. The ADON/IP further stated she had a future project planned to review all residents' immunizations status. The ADON/IP stated after reviewing residents' immunization status, she would consult with residents' physicians and make sure all residents are offered both pneumococcal vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 3 of 35 sample residents, that the residents were not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, residents were not regularly showered three times a week, as was their preference. Resident identifiers: 6, 22, 48. Findings include: 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included rheumatoid arthritis, spinal fusion, paraplegia, urinary tract infection, major depressive disorder, and neuropathy. On 3/14/22, resident 6 was interviewed and stated she was lucky to shower two times a week but only got 1 shower last week. They used to have a shower aide to do the showers now it was just the certified nursing assistants (CNA's). Resident 6 stated she would like to shower 3 times a week and that she has made the staff aware of this. On 3/15/22, resident 6's medical record was reviewed. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 6 resided in room [ROOM NUMBER]-B was in the column to shower on Mon, Wed, Fri in the morning. A Care Plan dated 12/6/21 revealed the resident had a potential for self care deficit related to pain, weakness and neurogenic bladder with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. Resident 6's task list was available for the past 90 days. Tasks were completed by the CNA's and revealed the following dates that resident 6 received a shower 3 times a week. a. December 2021, resident 6 received a shower, 3 times a week, for 1 out of 4 weeks in December. b. January 2022, resident 6 received a shower, 3 times a week, for 0 out of 4 weeks in January. c. February 2022, resident 6 received a shower, 3 times a week, for 0 out of 4 weeks in February. d. March 2022, resident 6 received a shower, 3 times a week, for 0 out of the 2 weeks that were evaluated during survey. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, hemiplegia of the right side, epilepsy, blindness of the right eye, major depressive disorder, dysphagia, and need for assistance with personal care. On 3/13/22 at 2:08 PM, an interview was conducted with resident 22. Resident 22 stated she would like to have more showers. Resident 22 stated she would like a shower every other day but usually only got them twice a week if that often. They are bad at giving us showers. On 3/15/22, resident 22's medical record was reviewed. A Care Plan dated 12/20/19 revealed the resident had a potential for self care deficit related to traumatic brain injury, weakness and blindness with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 22 resided in room [ROOM NUMBER]-B was in the column to shower on Mon, Wed, Fri in the morning. Resident 22's task list was available for the past 90 days. Tasks were completed by the CNA's and revealed the following dates that resident 22 received a shower 3 times a week. a. December 2021, resident 22 received a shower, 3 times a week, for 1 out of the 4 weeks in December. b. January 2022, resident 22 received a shower, 3 times a week, for 2 out of the 4 weeks in January. c. February 2022, resident 22 received a shower, 3 times a week, for 3 out of the 4 weeks in February. d. March 2022, resident 22 did not receive a shower, 3 times a week, for 0 weeks out of the 2 weeks that were evaluated during survey. 3. Resident 48 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses which included amputated stump, morbid obesity, type II diabetes, mild cognitive impairment, and mild intellectual disabilities. On 3/13/22 at 1:54 PM, an interview was conducted with resident 48. Resident 48 stated he did not get to bathe when he would like to, which was 3 times a week. He stated he only got to bathe 1 time a week and sometimes none. Resident 48 stated it had been like this for a while because the facility was low on staff. On 3/15/22, resident 48's medical record was reviewed. A Care Plan dated 11/1/21 revealed the resident had a potential for self care deficit related to incontinence, pain weakness and developmental delay with a goal to have all basic self care needs met at all times through the review date. An intervention developed was Teach techniques with adaptive equipment to help make bathing, hygiene and ADL tasks easier. A form titled Showers located behind the nurses' desk on the pin board revealed that the resident room numbers were separated into two columns. One column labeled Mon, Wed, Fri (Monday, Wednesday, Friday) and the other column labeled Tues, Thurs, Sat (Tuesday, Thursday, Saturday). Resident 48 resided in room [ROOM NUMBER]-B was in the column to shower on Mon, Wed, Fri in the morning. Resident 48's task list was available for the past 90 days. Tasks were completed by the CNA's and revealed the following dates that resident 48 received a shower 3 times a week. a. December 2021, resident 22 received a shower, 3 times a week, for 3 out of the 4 weeks of December. b. January 2022, resident 22 received a shower, 3 times a week, for 2 out of the 4 weeks of January. c. February 2022, resident 22 did not receive a shower, 3 times a week, for 0 weeks out of the 4 weeks of February. d. March 2022, resident 22 did not receive a shower, 3 times a week, for 0 weeks out of the 2 weeks that were evaluated during survey. On 3/15/22 at 11:57 AM, an interview was conducted with a Registered Nurse (RN). RN 2 stated there was a shower paper behind the nurses' desk that tells the nurse's and the CNA's when a resident needs to shower according to their room number. On 3/15/22 at 12:00 PM, an interview was conducted with CNA 2. CNA 2 stated the shower book will show when showers were done and any refusals. Showers are now done by the CNA's instead of restorative care. CNA 2 stated we are short staffed, but we try hard to get all our work done. 03/16/22 at 12:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the company policy was to ask the residents to shower but we cannot force them. It was expected that the residents get the showers they would like, and they tell us their shower preference when they first come to the facility. The DON stated we will encourage them to shower, offer help if they need it, or provide the shower if they cannot do it by themselves. The DON stated the residents are scheduled for their showers by where their room was located. The nurse was the one who will sign the refusal sheet if a resident does not want to shower. The DON stated that 90 percent of the time we have enough CNAs to get the showers done, but weekend have been hard. Most showers are done during the week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility did not 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. Specifically, staff were observed to enter transmission based precaution (TBP) rooms without the proper personal protective equipment (PPE) in place, staff were observed to enter the facility through a back entrance and walk down a hallway past residents prior to performing the COVID-19 screening process, staff were observed to have placed a spoon on the top of the medicine cart, then used the spoon to obtain applesauce from a communal container of applesauce, mix the applesauce with the medications and then administer the medication mixture to a resident, and the oxygen tubing for a resident was not routinely changed. Resident identifiers: 20, 69 and 228. Findings Include: On 3/15/22 at 9:53 AM, an observation was made of a Physical Therapy Assistant (PTA) entered room [ROOM NUMBER] with only a surgical mask in place. The signage on the door stated a mask, shield, gown, and gloves needed to be worn when entering the room. The PTA stopped at the door, read the signage, then entered the resident room and did not don any additional PPE. An immediate interview was conducted with the PTA, she stated you only need to wear PPE when you have contact with the resident. You do not need to wear it if you did not help the resident in isolation. On 3/15/23 at 9:55 AM, an interview was conducted with LPN 2. LPN 2 stated everyone should wear the PPE when they go into any room that has the sign. New admits are on precautions for 14 days or until there vaccination status was verified. But PPE should be worn if there was a sign on the door regardless. On 3/13/22 at 10:30 AM, a TBP sign was observed on the wall next to room [ROOM NUMBER]'s door. The TBP sign had instructions to check with nursing before entering the room. There was also a small plastic cart with personal protective equipment (PPE) in the hallway next to room [ROOM NUMBER]. On 3/13/22 at 10:43 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated the TBP sign and PPE cart near room [ROOM NUMBER] were present because resident 228, who was unvaccinated for COVID-19, was recently admitted and was being isolated in her room for 14 days. On 3/13/22 at 11:24 AM, Maintenance Man (MM) 1 was observed knocking on room [ROOM NUMBER]'s door and telling resident 228 that he needed to change the time on the clock due to Daylight Savings Time. MM 1 was then observed entering the room without donning PPE. On 3/15/22 at 10:35 AM, an interview was conducted with MM 1. The MM 1 stated that the PPE carts outside of residents' rooms are for residents that have infections. The MM 1 further stated that when he sees a PPE cart and a TBP sign near a resident's room that he asks the nurses what PPE he should wear when entering the room. On 3/16/22 at 9:48 AM, an interview was conducted with the facility's ADON/IP. The ADON/IP stated that maintenance workers receive training on TBP and on how to use PPE during their orientation when they first start working and she stated she reminds them daily about residents on TBP. On 03/15/22 at 9:35 AM, an observation was made of Occupational Therapy Assistant (OTA) 1 coming in the back door of the facility and walking through the facility to the front desk to complete the screening process for COVID-19. On 03/15/22 at 01:40 PM, an interview was conducted with the facility receptionist. The receptionist stated that staff come into the building via either the front or back door, and screen in at the reception desk prior to starting work. The receptionist stated visitors must come in through the front door because that is the door that is unlocked. The receptionist stated if they don't have a key card they can't get in the doors in the back. On 03/15/22 at 01:57 PM, an interview was conducted with OTA 1. OTA 1 stated that he came into the building through the back door and went right to the kiosk at the front desk, answered the COVID-19 screening questions, and got cleared to work. OTA 1 stated he believed if staff parked in the back of the building, they could come in the side or back doors. OTA 1 then walked to the door he had entered through earlier and noted there was a stop sign on the door indicating that everyone must enter the building through the front door. OTA 1 then acknowledged that he should have entered the facility through the front door. On 3/15/22 at 8:20 AM, an observation was made of Licensed Practical Nurse (LPN) 3. LPN 3 was observed to have dropped a plastic spoon on top of the medicine cart, then used the spoon to get applesauce from the communal container of applesauce. LPN 3 then used the plastic spoon to mix the medications with the applesauce and administer the medication mixture to resident 69. On 3/16/22 at 12:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated it was the expectation of the nurses use hand sanitizer and keep the work area clean when passing medications. The top of the cart was not considered always clean. Resident 20 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, C5-C7 complete, autonomic dysreflexia, acute pyelonephritis, thrombocytopenia, atrial flutter, non-ST elevation (NSTEMI) myocardial infarction, neuromuscular dysfunction of bladder, neurogenic bowel, hypothyroidism, and obstructive sleep apnea. On 3/13/22 at 1:03 PM, a Certified Nursing Assistant (CNA) was observed feeding resident his lunch meal. An oxygen concentrator was observed in the room near resident 20's bed. The oxygen tubing was not labeled and resident 20 could not remember when it was last changed. On 3/16/22 at 1:43 PM an interview was conducted with CNA 1. CNA 1 stated that oxygen tubing was changed monthly on the first Sunday of the month by the CNA Coordinator. On 3/16/22 at 1:45 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she thought oxygen tubing was changed weekly by the CNA Coordinator. On 3/16/22 at 1:48 PM, RN 1 introduced me to the Human Resource Manager and the Discharge Planner. RN 1 stated that they had both been prior CNA Coordinators in the facility. The Human Resource Manager and Discharge Planner stated that when they were CNA Coordinators that they would change oxygen tubing every Friday and label the tubing with the date it was changed. On 3/16/22 at 1:53 PM, an interview was conducted with resident 20. Resident 20 stated he didn't know when his oxygen tubing had last been changed but stated it had been a long time. On 3/16/22 at 2:01 PM, an interview was conducted with the facility's current CNA Coordinator. The CNA Coordinator stated she had just started in her new role as CNA Coordinator on 2/22/22. The CNA Coordinator stated she though that the prior CNA Coordinators changed oxygen tubing every month but stated she did know when resident 20's oxygen tubing was last changed. On 3/16/22 at 2:11 PM, an interview was conducted with the Corporate Resource Nurse (CRN) and the DON. They stated that oxygen tubing was changed weekly. The CRN and DON could not find a facility policy and procedure that included how often oxygen tubing should be changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 38 sample residents, that the facility did not ensure that the resident assessment information was accurate. Specifically, a resident on dialysis was documented as not being on dialysis on the Minimum Data Set (MDS) Assessment, and a resident who had sustained multiple falls were not documented on two Quarterly MDS Assessments that documented the falls. Resident identifiers: 3 and 9. Findings include: 1. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included acute respiratory failure, hypoxemia, end stage renal disease , dependence on renal dialysis, atherosclerosis, heart failure, hypertension, shortness of breath, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hyperlipidemia, non-st elevation myocardial infarction, peripheral vascular disease, peripheral neuropathy, and major depressive disorder. On 11/4/19 resident 9's medical record was reviewed. A physician's re-admission note on 6/20/18 documented 62(year old) M (male) with mult (multiple) med (medical) problems, long term resident at [facility name] sent emergently to hospital for uremic encephalopathy. Now with temp (temporary) dialysis cath (catheter) and started TIW (three times a week) on dialysis. [Note: this was resident 9's first documented dialysis treatment in the facility.] A Medicare Quarterly MDS assessment dated [DATE] documented under section O that resident 9 had not had dialysis performed while a resident of this facility and within the last 14 days. A review of resident 9's Dialysis Communication Forms revealed that resident 9 received dialysis treatments on 8/17/19, 8/15/19, 8/13/19, 8/10/19, 8/8/19, and 8/6/19. 2. Resident 3 was admitted on [DATE] and readmitted on [DATE] with diagnosis which included heart failure, fracture of left wrist and hand, fracture of nasal bones, atrial fibrillation, respiratory failure, dysphagia, encephalopathy, pain, hypertension, hyperlipidemia, insomnia, and muscle weakness. On 11/4/19 resident 3's medical record was reviewed. Nurses' progress notes revealed that resident 3 had falls on the following dates: a. On 2/10/19 with no injury. b. On 3/15/19 with no injury. c. On 5/24/19 with no injury. d. On 6/7/19 with a broken wrist and nose. e. On 7/17/19 with an abrasion to her leg. A Medicare Quarterly MDS assessment dated [DATE], with a look back period to 1/13/19, documented under section J that resident 3 had not had any falls since admission or reentry or the prior assessment. [Note: Resident 3 had a fall on 2/10/19 and 3/15/19.] A Medicare Quarterly MDS assessment dated [DATE], with a look back period to 4/25/19, documented under section J that resident 3 had one fall without injury since admission or the prior assessment. [Note: Resident 3 had a fall without injury on 5/24/19, a fall with a major injury on 6/7/19, and a fall with a minor injury on 7/17/19.] On 11/6/19 at 11:30 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that resident 9 should have been coded on the MDS on 8/18/19 as having dialysis treatments within the last 14 days. The MDS Coordinator further stated that she was on the fall committee and kept a log of all resident falls, stated that was what she referred to when she coded the MDS assessment. The MDS Coordinator stated that skin tears, bruises, and abrasions were considered minor injuries. The MDS Coordinator stated that fractures were considered major injuries. The MDS Coordinator stated that the April MDS assessment for resident 3 should have had at least one fall documented; stated that she had just started the job and didn't have a log at the time. The MDS Coordinator stated that the July MDS assessment for resident 3 should have had three falls documented, one with no injury, one with minor injury, and one with a major injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 1 of 38 sample residents that the facility did not provide an ongoing program to support residents choice, of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychological well-being of each resident, encouraging both independence and interaction in the community. Resident identifier: 13 Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, vertigo of central origin, anxiety disorder, chronic pain, syncope and collapse, and major depressive disorder. On 11/4/19 at approximately 10:26 AM, resident 13 was observed awake lying on her back in bed and an interview was conducted. Resident 13 stated she had not gone to the facility-sponsored group activities due to her rheumatoid arthritis. Resident 13 stated that it was too painful to sit in a wheelchair for an extended period of time. Resident 13 stated she had not been offered and was not getting any in-room activities from facility staff. Resident 13 further stated she was working with therapy to gain strength in hopes to be able to attend some of the facility-sponsored group activities. On 11/6/19 at approximately 8:26 AM, an interview was conducted with the Activities Director (AD). The facility AD stated she started working at the facility 10/1/19. The AD stated that resident 13 declines coming to the facility-sponsored group activities due to her rheumatoid arthritis. The AD stated that she visits with resident 13 one-on-one in her room and since she is new to the facility, the AD stated she has been focused on relationship building visits with resident 13. The AD further stated that it had been challenging because when she had gone into resident 13's room to visit one-on-one with resident 13, her roommate would try to divert the AD's time to her. On 11/6/19, resident 13's medical record was reviewed. Resident 13's Comprehensive Care Plan included the following Focus area: [Resident 13] exhibits impaired activity patterns manifested by: impaired mobility, need for adaptive equipment, sensory problems, poor health/pain limits activity involvement, need for reminders and assistance to/from activities, fatigue from treatments, mood problems. Date Initiated: 5/30/19 Created by: (Activities Aide) Goals a. Will maintain emotional health demonstrated through emotional expression, healthy coping skills, meaningful relationships and leisure through next review. b. Will accept at least 1 1:1 (one-on-one) visit OR attend 1 social group per week for social engagement/leisure involvement x (for) 90 days. c. Will participate in independent leisure activities daily x 90 days. d. Will continue life roles in accordance with preferences, strengths, and functional capacity weekly x 90 days. Date Initiated: 5/30/19 Created by: (Activities Aide) Interventions a. Monitor for satisfaction with leisure choices. b. Please post the calendar in room. c. Supply with independent leisure materials PRN. d. Support independent leisure choices. e. Invite and/or assist to/from group activities. f. Help ensure proper lighting & sufficient space for activities both in and out of room. g. Encourage and support the continuation of life roles. h. Monitor for fall risk. i. Monitor for diet precautions for food related activities. j. Provide adaptations to activities PRN: k. Cognitive: short interventions l. Vision: sit close to speaker m. Hearing: increase volume and speak clearly n. Communication: allow me time to speak or attend to non-verbal cues o. Physical: low energy programming p. Please support family/friend involvement & need for privacy during visits. q. Provide 1:1 visits PRN (as needed). r. Use validation to help express my feelings appropriately. Date Initiated: 5/30/19 Created by: (Activities Aide) Resident 13's Recreation Therapeutic Data Collection documented the following activity preferences: a. Talking/conversation b. Relaxation c. Outdoors d. Trips/outings e. TV/movies f. Music g. Reading/writing/being read to h. Spiritual/religious activities i. Social parties j. Family/friends Resident 13's Recreation Therapeutic Data Collection documented the following interview: a. How important is it to you to have book, newspapers, and magazines to read? 1. Very important b. How important is it to you to listen to music you like? 1. Very important c. How important is it to you to be around animals such as pets? 1. Very important d. How important is it to you to do things with people? 3. Not very important e. How important is it to you to keep up with the news? 3. Not very important f. How important is it to you to do your favorite activities? 3. Not very important g. How important is to you to go outside to get fresh air when the weather is good? 1. Very important h. How important is it to you to participate in religious services or practices? 1. Very important On 11/6/19 at approximately 9:31 AM, the AD provided monthly folders containing the facility's group Activity Calendars and Resident Participation Lists. The AD further stated that after reviewing the information she had that the facility had not provided adequate activities for resident 13. The monthly folders documented the following: a. May 2019 Folder: The Resident Participation Lists documented resident 13 received Individual Leisure activities. b. June 2019 Folder: The Resident Participation Lists documented resident 13 received Individual Leisure activities. c. July 2019 - No folder d. August 2019 Folder: The Resident Participation Lists did not include any activities provided to resident 13. e. September 2019 Folder: The Resident Participation Lists documented resident 13 received In Room/1:1 (one-on-one) activities. On 11/6/19 at approximately 10:44 AM, the AD's Clipboard, which included the Resident Participation Lists for October and November 2019, was reviewed in the AD's office. a. October 2019 Clipboard: The Resident Participation Lists did not include any activities provided to resident 13. b. November 2019 Clipboard: The Resident Participation Lists did not include any activities provided to resident 13.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 38 sample residents, that the facility did not ensure that residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and that the facility did not ensure that irregularities identified by the pharmacist were reported to the attending physician and director of nursing, and the reports were acted upon. Specifically, one resident had no irregularities noted by the facility pharmacist when taking an antipsychotic medication and one resident had a pharmacy recommendation that had not been followed up on in a timely manner. Resident identifiers: 50. Findings include: Resident 50 was admitted to the facility on [DATE] with diagnoses which included left pubic fracture, lumbar vertebra fracture, sacrum fracture, rib fracture, left arm cellulitis, gait abnormality, type 2 diabetes mellitus, asthma, hypertension, dementia without behavioral disturbance, and major depressive disorder. On 11/5/19 resident 50's medical record was reviewed. Physician's orders revealed that resident 50 was receiving Ziprasidone HCl Capsule 20 MG Give 20 mg by mouth two times a day related to UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE OTHER SPECIFIED MENTAL DISORDERS DUE TO KNOWN PHYSIOLOGICAL CONDITION. Treatment Administration Records (TARs) for resident 5 for September 2019, October 2019 and November 2019 revealed that facility staff were monitoring behaviors for # (number) of hallucinations two times a day and episodes of psycotic (sic) (screaming, hitting, bitting (sic) etc. two times a day. The TARs revealed that resident 50 had hallucinations on 10/19/19, 10/20/19 and 10/25/19 and episodes of psychosis on 10/19/19, 10/20/19 and 10/25/19. Documentation in resident 50's medical record revealed that 10/19/2019 14:21 **Event Initial Note Event Type: increased hallucinations and delusions Date of Event: 10/19/2019 Time of event : 0800 Detailed description of event (how, when, where, vitals, symptoms): pt (patient) has been pacing the halls this morning looking for the children she has been babysitting, pt refused to believe there are no children here today, pt called son several times this morning, and has asked all staff, visitors and patients for her children . [NOTE: No documentation could be located in the medical record to show that resident 50's hallucination was distressing to her. No documentation could be located in the medical record by the physician to show why the benefits of having an antipsychotic medication would outweigh the risks for resident 50. The PASRR (Preadmission Screening and Resident Review) Level I dated 6/11/19 revealed that resident 5's Level I screen indicates referral for Level II evaluation SMI (Serious Mental Illness) is not needed due to resident 5 not having a history of a serious mental illness. Physician Progress Notes revealed the following entries: a. 10/2/2019 21:42 (9:42 PM), Late Entry: Note Text: Subjective:Patient continues with facial dyskinesias and lip smacking. she remains stable in general otherwise. b. 10/10/2019 20:05 (8:05 PM), Late Entry: Note Text: Subjective: Patient is confused,agitated and pacing around the facility which is not normal for her. Urine dipstick + UA pending. labs done today are pending. she is not febrile and does not report she has any dysuria currently. movements/tardive dyskinesia. c. 10/23/2019 23:31 (11:31 PM), Agitation with mild anxiety? UTI (urinary tract infection)-Urine CS (culture and sensitivity) is pending Episodic agitation Plan: Pysch meds to be changed per her new symptoms . On 11/6/19 at 8:48 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the facility process for the psychotropic meetings was to include herself, the facility Assistant Director of Nursing (ADON), the facility Medical Director, the facility Social Service Director (SSW) and the facility pharmacist attend the psychotropic meeting. The facility DON stated that in the meeting, they would make sure that residents had an appropriate diagnoses for all psychotropic medications. The facility DON stated that she would look at resident 50's medical record for something from the facility Medical Director regarding a risk vs benefits. [NOTE: No additional information was provided by the facility DON.] On 11/6/19 at 12:15 PM, an interview was conducted with the facility SSW and the facility pharmacist. The facility pharmacist stated that there was some studies regarding the use of antipsychotics with Major Depressive Disorder and would forward the information. The facility pharmacist stated that because the antipsychotic was similar to the approved antipsychotics, that it was probably ok for resident 50 to take it. The facility SSW stated that she thought resident 50 had an approved diagnosis for the antipsychotic and that she had a PASRR level II for the use of the medication. According to the Nursing Drug Handbook by Wolters Kluwer, the black box warning revealed that In elderly patients with dementia-related psychosis, drug isn't indicated for use because of increased risk of death from CV events or infection. On 11/6/19, the facility pharmacist provided additional information regarding the use of antipsychotic medication for the treatment of Major Depressive Disorder. The additional information revealed the following: There has been substantial progress in the search for further treatment strategies for treatment-resistant MDD (Major Depressive Disorder); psychotropics augmentation other than antidepressants, and antidepressant switches and combinations regardless of antidepressant classes. Among them, augmentation treatment with atypical antipsychotic agents has been recognized as an important option. Moreover, second generation anti-psychotics have been an area of focus after successful augmentation using risperidone to SSRIs (Selective serotonin reuptake inhibitor) was found in 1991. Thereafter, three antipsychotis (sic) including olanzapine (2007), quetiapine extended release extended release (2007) and aripiprazole (2009) were approved by the US FDA as an augmentation therapy to antidepressants for treating MDD. Until recently, only 3 SGAs aripiprazole, quetipaine XR and olanzapine had a formal US (United States) FDA (Food and Drug Administration) approval in the treatment of MDD. Among them, olanzapine was approved for the treatment of TRD (treatment resistant depression), which is defined as MDD patients who did not respond to two separate trials of two or more than two antidepressants after an appropriate duration and dose, as a combined agent with fluoxetine. As stated earlier, Brexpiprazole just recently received FDA approval not only for schizophrenia, but also for the treatment of MDD as an adjunctive therapy to antidepressants in July 2015, which is the biggest change since 2013.15 In addition, a RPCT (unknown) was recently published for ziprasidone and lurasidone. A RPCT regarding asenapine, cariprazine, iloperidone, and sertindole have still not been published. Ziprasidone (Geodon): Unlike for amisulpride and risperidone, studies investigating the clinical effects in the treatment of MDD using ziprasidone have not been conducted until very recently. There was only one published RPCT for ziprasidone in the treatment of MDD as of 2012. One hundred and twenty (120) patients were randomized to ziprasidone monotherapy (drug-drug) for 12 weeks, placebo for 6 weeks followed by ziprasidone (placebo-drug) for 6 weeks, or placebo (placebo-placebo) for 12 weeks. The results did not show a statistically significant difference in response or remission rates among the three groups. However, the dosage of ziprasidone used might not have been sufficient to produce an antidepressant response. Relatively high pooled placebo responses and remission rates in phase II (29.9% and 32.7%) are another possible factor preventing the detection of the statistical significance of ziprasidone over placebo. Thereafter, 2 post-hoc analyses were recently published. [NAME] et al conducted a post-hoc analysis to investigate effects of ziprasidone monotherapy in treatment of psychomotor symptoms of MDD. The study involved drug-drug for 12 weeks, placebo-drug for 6 weeks respectively, and placebo-placebo for 12 weeks. In phase I, more significant improvement in HDRS-17 (F=5.95, p=0.017) and Quick Inventory of Depressive Symptomatology Scale, Self-Rated (QIDS-SR) (F=5.26, p=0.025) scores were found in the ziprasidone monotherapy group than in the placebo treatment among patients presenting psychomotor symptoms, although there was no significant differences in the HDRS-17 (F=2.32, p=0.15) and QIDS-SR (F=3.70, p=0.074) scores between the two treatment groups among those without psychomotor symptoms. In phase II, the ziprasidone monotherapy showed no superior efficacy over placebo in HDRS-17 and QIDS-SR scores in patients with or without psychomotor symptoms. [NAME] et al.70 conducted another post-hoc analysis utilizing data from the study by Papakostas to investigate the effects of ziprasidone monotherapy in anxious depression. The results failed to show superior efficacy of ziprasidone over placebo in anxious depression. The second RPCT investigating augmentation of ziprasidone to antidepressants in the treatment of MDD was very recently published.71 During an open label trial (phase I), patients with MDD were prescribed escitalopram for 8 weeks. The starting dosage of escitalopram was 10 mg/day, which could be escalated to 30 mg/day. After remaining on a stable escitalopram dosage for 4 weeks, patients were randomly assigned to a placebo group (N=68) or a ziprasidone augmentation group (N=71). Rates of clinical response were significantly higher for the adjunctive ziprasidone group (N=25 [35.2%]) than for the adjunctive placebo group according to the mixed-effects model with repeated-measures analyses (N=14 [20.5%], p=0.04). In addition, mean improvement in HAM-D total scores were significantly greater for ziprasidone (-6.4) than for placebo (-3.3) augmentation. [NOTE: the Ziprasidone (Geodon) had not been approved for Major Depressive Disorder.]

Based on observation, interview, and record review it was determined for 1 of 38 sample residents that the facility did not ensure that it was free from medication error rate of 5% or greater. Specifically, observations of thirty-three medication opportunities, on 11/6/19, revealed seven medication errors which resulted in a 21.21% medication error rate. Resident identifier: 51. Findings include: 1. On 11/6/19 at 7:30 AM, medication administration was observed with Licensed Practical Nurse (LPN) 1. Between 8:26 AM and 8:56 AM, LPN 1 was observed to prepare and administer the following medications to resident 51: a. Phos-Nak 280-160-250 mg (milligrams) 1 powder packet via naso-gastric (NG) tube. b. Potassium Chloride ER 10 mEq (mill-equivalents) via NG tube. c. Dexamethasone 8 mg via NG tube. d. Gabapentin 100 mg via NG tube. e. Multivitamin with minerals, 1 tablet via NG tube. f. Lasix 20 mg via NG tube. g. Diflucan 150 mg via NG tube. h. Ascorbic Acid 500 mg via NG tube. i. Metformin 1000 mg via NG tube. Resident 51's physician orders were reconciled against the administered medications, and revealed the following discrepancies: a. Phos-NaK Packet 280-160-250 mg (Potassium & Sodium Phosphates) 1 packet by mouth. b. Potassium Chloride ER Tablet 10 mEq by mouth. c. Dexamethasone 8 mg by mouth. d. Multivit/Mineral Tablet 1 tablet by mouth. e. Furosemide Tablet 20 mg by mouth. f. Ascorbic Acid 500 mg by mouth. g. MetFORMIN Tablet 1000 mg mouth. It should be noted that all of the medications list above were ordered to be administered orally. A review of resident 51's diet order started on 10/3/19 revealed an order for Regular diet Pureed texture, Regular consistency, May have regular diet and snacks. [Note: resident 51 was able to have oral intake.] A review of resident 51's care plan had a documented intervention under multiple care areas of Labs and medications per order. On 11/6/19 at 8:53 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 51 was able to take all of her medications orally, but that resident 51 always refused. [Note: LPN 1 did not offer resident 51 the option to take her medication orally.] LPN 1 stated that resident 51's family wanted resident 51 to still have the option to take her medication orally, which was why the orders all said by mouth. On 11/6/19 at 10:47 AM, an interview was conducted with Director of Nursing (DON). The DON stated that if resident 51 preferred to take all of her medication through the NG tube, then the doctor should have been contacted and the orders should have been changed. [Note: the DON provided further information that the orders were changed to May be given PO (by mouth) or per tube as patient allows.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 2 of 38 sample residents was free of significant medication errors. Specifically, two residents were administered crushed potassium extended released (ER). Resident identifier: 51 and 206. Findings include: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of stomach, hyponatremia, weakness, anorexia, nutritional anemia, type 2 diabetes mellitus, hyperlipidemia, hypertension, mononeuropathy of left lower limb, protein-calorie malnutrition, and dysphagia. On 11/6/19 at 8:26 AM, an observation was made of medication administration to resident 51 by Licensed Practical Nurse (LPN) 1. LPN 1 prepped Potassium Chloride ER 10 mEq (mill-equivalents), LPN 1 was observed to crush the potassium and place it in a cup of water. LPN 1 was then observed to draw up the water and crushed potassium into a syringe and administered it to resident 51 via her naso-gastric (NG) tube. On 11/6/19 at 8:53 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 51's potassium was one that could be crushed. On 11/6/19 at 10:10 AM, a phone interview was conducted with Pharmacist 1. Pharmacist 1 reviewed which potassium was administered to resident 51 and stated that one should not be crushed. 2. Resident 206 was admitted to the facility on [DATE] with diagnoses which included sepsis due to streptococcus pneumoniae, ischemic cardiomyopathy , atrial fibrillation , history of transient ischemic attack and cerebral infarction, chronic obstructive pulmonary disease, rheumatic mitral valve disease, presence of cardiac pacemaker, non-st elevation myocardial infarction, atherosclerotic heart disease, emphysema, hyperlipidemia, acute kidney failure,, supraventricular tachycardia, drug induced sub-acute dyskinesia, chest pain, aortocoronary bypass graft, muscle weakness, and dysphagia. Resident 206's medical record was reviewed on 11/4/19. A nurses' progress note dated 11/1/19 documented . Meds (medications) whole except K+ (potassium) crushed w/o (without) incident. Another nurses' progress note dated 11/3/19 documented . Meds whole except K+ crushed w/o incident. A final nurses' progress note dated 11/5/19 documented . Meds whole except K+ crushed w/o incident. On 11/4/19 at 9:31 AM, an observation was made of resident 206's potassium tablets in the South Hall medication cart. The tablets were labeled as Potassium Chloride ER 20 mEq. On 11/6/19 at 6:35 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 206 took all his medications whole except the potassium which the nurse crushed and mixed in applesauce. RN 1 stated that was a medication that was not supposed to be crushed though. On 11/6/19 at 10:16 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 206 took his medication whole except the potassium which the nurses crushed. LPN 1 stated that she was going to contact the doctor to get an order to crush the potassium. Upon observation of resident 206's potassium pills, LPN 1 verified that they were an extended release, stated extended release medications were not supposed to be crushed because the resident would get the entire dose all at once. On 11/6/19 at 10:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that potassium should not be crushed, stated that she was unaware that staff were crushing the potassium for residents 51 and resident 206.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medications. Specifically, medications that had expired were still available for use. Findings include: 1. On [DATE] at 9:20 AM, the South Hall medication cart was observed. There was a Glucagon Emergency Kit for Low Blood Sugar 1 milligram injection with an expiration date on the package of 5/2019. The Pharmacy label had an expiration date of 3/2020. On [DATE] at 9:27 AM, the Central Hall medication cart was observed. The cart did not contain a Glucagon Emergency Kit for Low Blood Sugar. On [DATE] at 9:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the expiration date on the product package was the correct expiration date, and the pharmacy label was incorrect. On [DATE] at 9:27 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 verified that the Central Hall medication cart did not contain a Glucagon Emergency Kit for Low Blood Sugar. RN 1 stated that the South Hall medication cart had a Glucagon Emergency Kit for Low Blood Sugar, stated that if she needed one then she would get it from the South Hall Cart. On [DATE] at 10:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that an expired Glucagon Emergency Kit for Low Blood Sugar would not be as effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 3 was admitted on [DATE] and readmitted on [DATE] with diagnosis which included heart failure, fracture of left wrist and hand, fracture of nasal bones, atrial fibrillation, respiratory failure, dysphagia, encephalopathy, pain, hypertension, hyperlipidemia, insomnia, and muscle weakness. On 11/4/19 at 2:38 PM, resident 3 was observed lying in her bed. Resident 3 had no falls mats on the floor by her bed. Resident 3's call light was observed to be in her recliner which was not accessible from the bed. On 11/5/19 at 7:26 AM, an observation was made of resident 3's room. There were no fall mats observed to be anywhere in resident 3's room. On 11/5/19 at 9:52 AM, an observation was made of resident 3 sitting in her wheelchair in her room. Resident 3's call light was behind her on her nightstand, which was not accessible from her wheelchair. On 11/5/19 at 1:52 PM, an observation was made of resident 3. Resident 3 was sitting in her recliner; resident 3's tab alarm was not in place. Resident 3's medical record was reviewed on 11/4/19. Resident 3's fall care plan was initiated on 1/4/17, and documented a focus area of [Resident 3] is at risk for falls/injuries r/t (related to) heart failure, balance problem, needs assistance with transfers, poor safety awareness. Two goals were entered and initiated on 1/4/17 of Resident will have no falls/injuries daily through next 90day review AND Safety measures will be maintained to prevent or lessen any injury from fall. Resident 3's initial fall care plan interventions initiated on 1/4/17 were: a. Accompany resident during ambulation utilizing a transfer safety belt if he/she is weak or dizzy provide ambulatory aids (e.g. walker, cane) if resident is weak or unsteady on feet instruct resident to ambulate in well-lit areas and to utilize handrails if needed b. Assess for any adaptive equipment needed. Encourage use if necessary c. Check that adaptive aids are working properly and in good repair. d. Encourage resident to request assistance whenever needed; have call signal within easy reach, instruct client to wear well-fitting slippers/shoes with nonslip soles and low heels when ambulating keep floor free of clutter and wipe up spills promptly e. if resident is confused or irrational: reorient frequently to surroundings and necessity of adhering to safety precautions provide appropriate level of supervision f. Keep frequently used items within easy reach. g. Keep room free and clear of clutter h. Maintain regular toileting at set intervals and/or a continence program; provide easy access to urinals and bedpans. Additional care plan interventions initiated on 1/9/17 were: i. LOW BED IN PLACE FOR FALL RISK j. MAT ON FLOOR BESIDE BED FOR HIGH FALL RISK k. PRESSURE ALARM IN PLACE FOR FALL RISK Nurses' progress notes and fall review notes revealed that resident 3 had documented falls on the following dates: a. 2/10/19 unwitnessed fall Background: no hx (history) of falls was sitting in w/c (wheelchair) with side table in front of pt (patient). later found sitting on her foot rests, no apparent injuries noted, reddened area on R (right) mid buttock. Interventions entered on resident 3's care plan initiated on 2/14/19 were assure that lighting is adequate, instruct resident to call for assist with transfer, invite to daily in house activities and encourage participation, and monitor resident for balance and steadiness. All of these interventions were removed from resident 3's care plan on 4/8/19. An IDT (interdisciplinary team) Event Review form dated 2/11/19 documented interventions of make sure proper positioning and foot rests locked when up in wc (wheelchair). [Note: these interventions were not entered on resident 3's care plan.] b. 3/15/19 Pt (patient) slipped from w/c to sitting on the floor. Assisted back to bed. Vital signs stable. No injuries visible. Daughter spoke to pt on phone and she denied any pain. [Note: this fall was not reported to nurse management, and no interventions were initiated.] c. 5/24/19 IDT team into assess resident post fall on 5/24/19. Staff stated residents bed in lowest position and it appears resident slid/rolled out of bed. ROM (range of motion) intact, no outward s/s (signs or symptoms) of pain. Resident is nonverbal and could not state what she was trying to do. Staff reports resident did have a wet brief and was changed. An IDT Event Review form dated 5/24/19, documented interventions fall mat + low bed. [Note: Fall mat and low bed interventions had already been initiated on resident 3's care plan on 1/9/17.] d. 6/7/19 at 5:00 AM, Pt was walking with CNA (certified nursing assistant) and walker to the bathroom and fell when CNA was with her. Neuro (neurological) checks started. Pt cut her bridge of nose with bleeeding (sic). Small laceration on left arm and left wrist. with a follow up note at 7:25 AM When this nurse got here resident had fallen with previous shift. Noc (night) nurse stated that cna was walking her to the bathroom and that she fell forward and hit her face into her fww (front wheel walker) but that she had hold of her pants and she did not go to floor. On my shiftresident's (sic) nose started to swell and blacken, also swelling noted to left wrist. Ice packs applied to both sites. Resident sent to [name of hospital] emergency room. Another follow up note at 2:32 PM documented Resident returned from [name of hospital] with a broken nose and broken wrist. Wrist has a cast that is not suppose to get wet. An IDT Event Review form dated 6/7/19, documented interventions of use w/c for early am (morning) toileting. Use gait belt when walking. [Note: These interventions were initiated on resident 3's care plan.] e. 7/17/19 Pt was found laying on the floor of her room in the doorway at 2045 (8:45 PM) 7/17/19. Another pt saw [NAME] on the floor and alerted staff. Pt was assessed for injuries and pain and helped to a sitting position. An abrasion was found to L (left) outer ankle. An IDT Event Review form dated 7/18/19 documented an intervention of tab alarm placed. [Note: This intervention had previously been initiated on resident 3's care plan on 1/9/17.] On 11/5/19 at 1:53 PM, an interview was conducted with CNA 2. CNA 2 stated that she was very familiar with resident 3. CNA 2 stated that to prevent falls resident 3 has a tab alarm and was supposed to have a low bed at night. CNA 2 stated that the fall prevention interventions were communicated to the CNA's verbally; stated they did not have any type of hard copy or digital communication. CNA 2 stated that resident 3 never refused interventions. On 11/5/19 at 1:56 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was very familiar with resident 3. RN 1 stated that resident 3 was at risk for falls because of her impulsiveness with self-transferring. RN 1 stated that resident 3 had fall mats, call light within reach, and a tab alarm for fall prevention interventions. RN 1 stated that the nurses never checked the care plan for interventions. On 11/5/19 at 3:05 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the IDT team met after each fall and initiated interventions, stated that the interventions were put in the resident care plan. The DON stated that there should be a new intervention after each fall, stated that interventions were evaluated for effectiveness if the resident fell again. On 11/5/19 at 3:17 PM, a follow up interview was conducted with the DON. The DON stated that resident 3 did not have further interventions ordered because she has the right to fall. The DON stated that if it were up to her she would get resident 3 a lap buddy, stated that is a restraint though and those weren't allowed. The DON stated the resident 3's daughter did not want to move resident 3's room closer to the nurses' station and at some point you are just exhausted of interventions. The DON provided no further information about duplicate intervention use, nor communication of interventions to floor staff. Based on observation, interview and record review it was determined for 3 of 38 sample residents that the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident identifiers: 3, 38, 50 Findings include: 1. Resident 38 was admitted to the facility initially on 1/17/19 and again on 2/18/19 with diagnoses which included metabolic encephalopathy, chronic kidney disease, anxiety disorder, dementia with behavioral disturbances, and major depressive disorder. On 11/4/19 at approximately 11:52 AM, resident 38 was observed lying on her side sleeping in bed. The call light button was within reach. Resident 38's room was clean and free from tripping hazards. The bed was in the low position against the wall and there was a fall mat on the floor next to the bed. On 11/5/19 at approximately 3:06 PM, the Director of Nursing (DON) was interviewed. The DON described the facility's process following a resident fall. The DON stated that a nurse assesses the resident for injuries and completes a post-fall assessment. The resident's physician is notified through secure communication in Point Click Care (PCC), the facility's electronic medical record system. The DON stated that an Interdisciplinary Team (IDT) will meet together the next day to review the event and identify a root cause for the fall. New fall prevention interventions are determined by the IDT. The DON then adds the new fall prevention interventions to the resident's Care Plan. On 11/5/19 resident 38's medical record was reviewed. Resident 38's Comprehensive Care Plan included the following Focus area: [Resident 38] is at risk for falls/injuries r/t (related to) cognitive impairment, fall history, gait and balance, use of antidepressants, use of antipsychotic drugs, visual impairment, generalized weakness, poor safety awareness. a. Actual fall 4/24/19 b. Actual fall 5/29/19 no injuries c. Actual fall 7/13/19 no injuries d. Actual fall 8/4/19 no injuries e. Actual fall 8/30/19 no injuries f. Actual fall 10/8/19 Date Initiated: 2/20/19 Created by: Licensed Practical Nurse 2 (LPN 2) Revision by: Director of Nursing (DON) Note: Resident 38 had three other documented falls (i.e., 3/28/19, 3/31/19, and 6/17/19), which were not listed above in resident 38's Care Plan. Goal a. Safety measures will be maintained to prevent or lessen any injury from fall. Date Initiated: 2/20/19 Created by: LPN 2 Revision by: Registered Nurse 3 (RN 3) Revision by: RN 3 Target Date: 6/6/19 b. Resident will have no falls/injuries daily through next 90 day review Date Initiated: 9/23/19 Created by: Director of Nursing (DON) Target Date: 12/3/19 Interventions a. Assess for any adaptive equipment needed. Encourage use if necessary Date Initiated: 2/20/19 Created by: LPN 2 b. Do not rush resident; allow adequate time for ambulation to the bathroom and in hallway instruct and assist resident to rise and change positions slowly in order to reduce dizziness associated with postural hypotension perform actions to improve cardiac output in order to improve cerebral blood flow and subsequently reduce dizziness, syncope, agitation, and confusion Date Initiated: 2/20/19 Created by: LPN 2 c. RESOLVED: Encourage early mobility programs, such as walking to and from the dining room. Participate in a scheduled exercise program. Date Initiated: 2/20/19 Created by: LPN 2 Revision by: RN 3 Resolved Date: 4/8/19 d. RESOLVED: Encourage resident to wear non skid soles for shoes Date Initiated: 2/20/19 Created by: LPN 2 Revision by: RN 3 Resolved Date: 4/8/19 e. RESOLVED: Ensure that lighting is adequate and lights are functioning, including night lights. Date Initiated: 2/20/19 Created by: LPN 2 Revision by: RN 3 Resolved Date: 4/8/19 f. RESOLVED: Ensure that the clothing does not cause tripping; and that rubber soled, heeled shoes or nonskid slippers are worn. Date Initiated: 2/20/19 Created by: LPN 2 Revision by: RN 3 Resolved Date: 4/8/19 g. if resident is confused or irrational: reorient frequently to surroundings and necessity of adhering to safety precautions provide appropriate level of supervision Date Initiated: 2/20/19 Created by: LPN 2 h. Implement measures to prevent falls: keep bed in low position with side rails up when client is in bed keep needed items within easy reach Date Initiated: 2/20/19 Created by: LPN 2 i. Keep frequently used items within easy reach. Date Initiated: 2/20/19 Created by: LPN 2 j. Maintain regular toileting at set intervals and/or a continence program; provide easy access to urinals and bedpans. Date Initiated: 2/20/19 Created by: LPN 2 k. RESOLVED: Monitor for any weakness or instability. Notify MD PRN Date Initiated: 2/20/19 Created by: LPN 2 Revision by: RN 3 Resolved Date: 4/8/19 l. Remove pantyhose from Pts room. Date Initiated: 4/25/19 Created by: RN 4 m. Use floor mats when in bed. Date Initiated: 8/19/19 Created by: RN 3 n. Use personal or pressure sensor alarms when the resident is in a chair or bed. Date Initiated: 8/19/19 Created by: RN 3 o. RESOLVED: Wander guard daily Date Initiated: 4/8/19 Created by: RN 3 Revision by: RN 3 Resolved Date: 8/15/19 Resident 38 had the following nine documented falls from admission, 1/17/19 through 10/8/19: a. On 3/28/19 at 3:59 PM, resident 38 had an unwitnessed fall. There were no injuries noted. On 3/29/19 at 2:48 PM, an IDT meeting was held to review resident 38's fall. There were no new fall prevention interventions added to resident 38's Care Plan following this fall. b. On 3/31/19 at 3:26 AM, resident 38 had an unwitnessed fall. There were no injuries noted. On 4/2/19 at 2:41 PM, an IDT meeting was held to review resident 38's fall. There were five (2/20/19 initiated) fall prevention interventions on resident 38's Care Plan documented as RESOLVED on 4/8/19, but no new fall prevention interventions were added to resident 38's Care Plan following this fall. c. On 4/24/19 at 10:49 PM, resident 38 had an unwitnessed fall. Resident 38 received a skin tear to her right elbow. On 4/25/19 at 9:52 AM, an IDT meeting was held to review resident 38's fall. One new fall prevention intervention (i.e., Remove pantyhose from Pts room) was added to resident 38's Care Plan. d. On 5/29/19 at 5:41 PM, resident 38 had an unwitnessed fall. There were no injuries noted. On 5/31/19 at 11:07 AM, an IDT meeting was held to review resident 38's fall. There were no new fall prevention interventions added to resident 38's Care Plan following this fall. e. On 6/17/19 at 7:46 PM, resident 38 had an unwitnessed fall. There were no injuries noted. On 6/18/19 at 3:00 PM, an IDT meeting was held to review resident 38's fall. There were no new fall prevention interventions added to resident 38's Care Plan following this fall. f. On 7/13/19 at 10:52 AM, resident 38 had an unwitnessed fall. There were no injuries noted. On 7/17/19 at 11:35 AM, an IDT meeting was held to review resident 38's fall. One new fall prevention intervention (i.e., Resident was moved to a room closer to the Nurse's Desk) was implemented. g. On 8/4/19 at at 6:30 PM, resident 38 had an unwitnessed fall. There were no injuries noted. On 8/6/19 at 2:13 PM, an IDT meeting was held to review resident 38's fall. Two new fall prevention interventions (i.e., Use floor mats when in bed, and use personal or pressure sensor alarms when the resident is in a chair or bed.) were added to resident 38's Care Plan. h. On 8/30/19 at 4:38 PM, resident 38 had an unwitnessed fall. There were no injuries noted. There was no documented IDT meeting in resident 38's Progress Notes and there were no new fall prevention interventions added to resident 38's Care Plan following this fall. i. On 10/8/19 at 7:50 PM, resident 38 had an unwitnessed fall. Resident 38 received a skin tear to her left wrist. On 10/9/19 at 10:05 AM, an IDT meeting was held to review resident 38's fall. There were no new fall prevention interventions added to resident 38's Care Plan following this fall. 3. Resident 50 was admitted to the facility on [DATE] with diagnoses which included a history of falls, left pubic fracture, lumbar vertebra fracture, sacrum fracture, rib fracture, left arm cellulitis, gait abnormality, type 2 diabetes mellitus, asthma, hypertension, dementia without behavioral disturbance, and major depressive disorder. On 11/4/19 resident 50 was observed in her bed without the fall mat in place on the floor next to the bed. On 11/5/19 resident 50 was observed in her bed without the fall mat in place on the floor next to the bed. On 11/5/19 resident 50's medical record was reviewed. Resident 50's medical record revealed the following falls: a. 3/15/19 with resident 50 being assessed as a moderate risk for falls. b. 3/18/19 with resident 50 being assessed as a moderate risk for falls. c. 3/21/19 with resident 50 being assessed as a moderate risk for falls. d. 3/26/19 with resident 50 being assessed as a high risk for falls. e. 4/17/19 with resident 50 being assessed as a high risk for falls. f. 5/2/19 with resident 50 being assessed as a high risk for falls. g. 5/13/19 with resident 50 being assessed as a high risk for falls. h. 7/18/19 with resident 50 being assessed as a moderate risk for falls. The medical record revealed that resident 50 sustained skin tears and bruising with the falls on 3/18/19 and 5/2/19. The care plan dated 4/8/19 for resident 50 revealed that [Resident 50] is at risk for injuries r/t recent history of falls on 3/15/19, 03/25 and 03/26 d/t (due to) balance problem and generalized weakness. actual fall 4/17/19-no injury Actual fall 5/2/19 no injury Actual fall 5/13/19-no injuries actual fall 7/18/19-no injuries The goal for resident 50 was Resident will be free from injury r/t falls at all times through next 90day review The interventions included Ambulate as resident is capable, Assure that lighthing (sic) is adequate, Be careful when getting a mostly immobile client up, Be sure to lock the bed and wheelchair and have sufficient personnel to protect client from falls, Call light close and answered promptly, Encourage use of non skid shoes and socks, Evaluate client's medications to determine whether medications increase the risk of falling; consult with physician regarding client's need for medication if appropriate, Instruct to call for assist with transfers, Monitor blood pressure if on hypertensive medications, Monitor resident for steadiness and balance, Monitor vitals, Place a fall-prone client in a room that is near the nurses' station. Such placement allows more frequent observation of the client. toileting q 2 hours for fall prevention. [NOTE: The medical record revealed that resident 50 did not have a care plan in place for her history of falls nor for her actual falls in the facility until 4/8/19. The care plan interventions were added at that time with the exception that resident 50 was to be toileted every 2 hours for fall prevention that was added on 4/26/19. The care plan revealed that the facility did not add an intervention after each fall in an attempt to prevent resident 50 from falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 3 of 38 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility staff did not provide adequate supervision to prevent falls from occurring and care planned interventions were not implemented. Resident identifiers: 3, 38, and 50. Findings include: 1. Resident 3 was admitted on [DATE] and readmitted on [DATE] with diagnosis which included heart failure, fracture of left wrist and hand, fracture of nasal bones, atrial fibrillation, respiratory failure, dysphagia, encephalopathy, pain, hypertension, hyperlipidemia, insomnia, and muscle weakness. On 11/4/19 at 2:38 PM, resident 3 was observed lying in her bed. Resident 3 had no falls mats on the floor by her bed. Resident 3's call light was observed to be in her recliner which was not accessible from the bed. On 11/5/19 at 7:26 AM, an observation was made of resident 3's room. There were no fall mats observed to be anywhere in resident 3's room. On 11/5/19 at 9:52 AM, an observation was made of resident 3 sitting in her wheelchair in her room. Resident 3's call light was behind her on her nightstand, which was not accessible from her wheelchair. On 11/5/19 at 1:52 PM, an observation was made of resident 3. Resident 3 was sitting in her recliner; resident 3's tab alarm was not in place. Resident 3's medical record was reviewed on 11/4/19. Resident 3's fall care plan was initiated on 1/4/17, and documented a focus area of [Resident 3] is at risk for falls/injuries r/t (related to) heart failure, balance problem, needs assistance with transfers, poor safety awareness. Two goals were entered and initiated on 1/4/17 of Resident will have no falls/injuries daily through next 90day review AND Safety measures will be maintained to prevent or lessen any injury from fall. Resident 3's initial fall care plan interventions initiated on 1/4/17 were: a. Accompany resident during ambulation utilizing a transfer safety belt if he/she is weak or dizzy provide ambulatory aids (e.g. walker, cane) if resident is weak or unsteady on feet instruct resident to ambulate in well-lit areas and to utilize handrails if needed b. Assess for any adaptive equipment needed. Encourage use if necessary c. Check that adaptive aids are working properly and in good repair. d. Encourage resident to request assistance whenever needed; have call signal within easy reach, instruct client to wear well-fitting slippers/shoes with nonslip soles and low heels when ambulating keep floor free of clutter and wipe up spills promptly e. if resident is confused or irrational: reorient frequently to surroundings and necessity of adhering to safety precautions provide appropriate level of supervision f. Keep frequently used items within easy reach. g. Keep room free and clear of clutter h. Maintain regular toileting at set intervals and/or a continence program; provide easy access to urinals and bedpans. Additional care plan interventions initiated on 1/9/17 were: i. LOW BED IN PLACE FOR FALL RISK j. MAT ON FLOOR BESIDE BED FOR HIGH FALL RISK k. PRESSURE ALARM IN PLACE FOR FALL RISK A review of resident 3's physician order's revealed the following fall prevention orders stated on 1/5/17, Low bed in place due to fall risk AND Mat on floor beside bed for high fall risk. On 7/18/19 a physician's order was entered for Fall alarm for use in bed and chair. Check placement every shift r/t (related to) poor safety awareness. Nurses' progress notes and fall review notes revealed that resident 3 had documented falls on the following dates: a. 2/10/19 unwitnessed fall Background: no hx (history) of falls was sitting in w/c (wheelchair) with side table in front of pt (patient). later found sitting on her foot rests, no apparent injuries noted, reddened area on R (right) mid buttock. Interventions entered on resident 3's care plan initiated on 2/14/19 were assure that lighting is adequate, instruct resident to call for assist with transfer, invite to daily in house activities and encourage participation, and monitor resident for balance and steadiness. All of these interventions were removed from resident 3's care plan on 4/8/19. An IDT (interdisciplinary team) Event Review form dated 2/11/19 documented interventions of make sure proper positioning and foot rests locked when up in wc (wheelchair). [Note: these interventions were not entered on resident 3's care plan.] b. 3/15/19 Pt (patient) slipped from w/c to sitting on the floor. Assisted back to bed. Vital signs stable. No injuries visible. Daughter spoke to pt on phone and she denied any pain. [Note: this fall was not reported to nurse management, no follow up was completed, and no interventions were initiated.] c. 5/24/19 IDT team into assess resident post fall on 5/24/19. Staff stated residents bed in lowest position and it appears resident slid/rolled out of bed. ROM (range of motion) intact, no outward s/s (signs or symptoms) of pain. Resident is nonverbal and could not state what she was trying to do. Staff reports resident did have a wet brief and was changed. An IDT Event Review form dated 5/24/19, documented interventions fall mat + low bed. [Note: Fall mat and low bed interventions had already been entered as a physician order on 1/5/17, and initiated on resident 3's care plan on 1/9/17.] d. 6/7/19 at 5:00 AM, Pt was walking with CNA (certified nursing assistant) and walker to the bathroom and fell when CNA was with her. Neuro (neurological) checks started. Pt cut her bridge of nose with bleeeding (sic). Small laceration on left arm and left wrist. with a follow up note at 7:25 AM When this nurse got here resident had fallen with previous shift. Noc (night) nurse stated that cna was walking her to the bathroom and that she fell forward and hit her face into her fww (front wheel walker) but that she had hold of her pants and she did not go to floor. On my shiftresident's (sic) nose started to swell and blacken, also swelling noted to left wrist. Ice packs applied to both sites. Resident sent to [name of hospital] emergency room. Another follow up note at 2:32 PM documented Resident returned from [name of hospital] with a broken nose and broken wrist. Wrist has a cast that is not suppose to get wet. An IDT Event Review form dated 6/7/19, documented interventions of use w/c for early am (morning) toileting. Use gait belt when walking. [Note: These interventions were not entered as a physician's order, nor initiated on resident 3's care plan.] e. 7/17/19 Pt was found laying on the floor of her room in the doorway at 2045 (8:45 PM) 7/17/19. Another pt saw [NAME] on the floor and alerted staff. Pt was assessed for injuries and pain and helped to a sitting position. An abrasion was found to L (left) outer ankle. An IDT Event Review form dated 7/18/19 documented an intervention of tab alarm placed. [Note: A physician's order for a tab alarm was entered 7/18/19, this intervention had previously been initiated on resident 3's care plan on 1/9/17.] Resident 3's fall risk assessments were reviewed, and revealed the following results: [Note: any score over 15 indicates a high risk for falls.] a. On 10/17/18 a score of 16 indicated resident 3 was a high risk for falls. b. On 2/10/19 a score of 18 indicated resident 3 was a high risk for falls related to poor memory, total incontinence, unable to independently come to a standing position, loss of balance while standing, unable to walk a straight path, required extensive assistance for ambulation, short shuffling steps, used an assistive device, poorly fitting shoes, and decreased muscle coordination. c. On 5/24/19 a score of 19 indicated resident 3 was a high risk for fall related to a history of falls, high risk medications, poor memory, impaired vision, total incontinence, disorientation, unable to independently come to a standing position, unable to walk a straight path, required extensive assistance for ambulation, short shuffling steps, and changes in gait when walking through doorways. d. On 6/7/19 a score of 25 indicated resident 3 was a high risk for fall related to a history of falls, high risk medications, poor memory, total incontinence, unable to independently come to a standing position, loss of balance while standing, unable to walk a straight path, required extensive assistance for ambulation, short shuffling steps, changes in gait when walking through doorways, jerking or instability when turning, and used an assistive device. On 11/5/19 at 1:53 PM, an interview was conducted with CNA 2. CNA 2 stated that she was very familiar with resident 3. CNA 2 stated that to prevent falls resident 3 has a tab alarm and was supposed to have a low bed at night. CNA 2 stated that the fall prevention interventions were communicated to the CNA's verbally; stated they did not have any type of hard copy or digital communication. CNA 2 stated that resident 3 never refused interventions. On 11/5/19 at 1:56 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was very familiar with resident 3. RN 1 stated that resident 3 was at risk for falls because of her impulsiveness with self-transferring. RN 1 stated that resident 3 had fall mats, call light within reach, and a tab alarm for fall prevention interventions. RN 1 stated that the nurses never checked the care plan for interventions, stated that interventions were entered as a physician's order to communicate them to staff. RN 1 stated that staff conducted fall risk assessments on residents quarterly, stated that the results indicated if a resident was high risk for falls. RN 1 could not state what was done if a resident was high risk for falls. RN 1 stated that resident 3 never refused interventions. On 11/5/19 at 3:05 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that fall risk assessments were conducted maybe quarterly and post fall. The DON stated that if someone was a high risk for falls, staff just checked that interventions were in place. The DON stated that the IDT team met after each fall and initiated interventions, stated that the interventions were put in the resident care plan. The DON stated that there should be a new intervention after each fall, stated that interventions were evaluated for effectiveness if the resident fell again. On 11/5/19 at 3:17 PM, a follow up interview was conducted with the DON. The DON stated that resident 3 did not have further interventions ordered because she has the right to fall. The DON stated that if it were up to her she would get resident 3 a lap buddy, stated that is a restraint though and those weren't allowed. The DON stated the resident 3's daughter did not want to move resident 3's room closer to the nurses' station and at some point you are just exhausted of interventions. The DON provided no further information about duplicate intervention use, nor communication of interventions to floor staff. 3. Resident 38 was admitted to the facility initially on 1/17/19 and again on 2/18/19 with diagnoses which included metabolic encephalopathy, chronic kidney disease, anxiety disorder, dementia with behavioral disturbances, and major depressive disorder. On 11/4/19 at approximately 11:52 AM, resident 38 was observed lying on her side sleeping in bed. The call light button was within reach. Resident 38's room was clean and free from tripping hazards. The bed was in the low position against the wall and there was a fall mat on the floor next to the bed. On 11/5/19 at 10:47 AM, resident 38 was observed sitting in a recliner next to her bed in her room. a tab alarm was observed attached to resident 38's blouse and the call light was within reach. On 11/6/19 at 8:09 AM, resident 38 was observed lying on her side sleeping in her bed. The bed was in the low position with a fall mat on the side of the bed. A tab alarm was attached to resident 38's blouse. On 11/6/19 at 12:37 PM, resident 38 was observed sitting in a recliner in the main foyer near the Nurse's Desk. On 11/5/19 at approximately 2:43 PM, an interview was conducted with CNA 3 (Certified Nursing Assistant 3). CNA 3 stated that facility CNAs have helped resident 38 from falling by keeping the bed in the low position with a floor mat on the side of the bed. CNA 3 further stated that they attached a tab alarm to resident 38 so they know when she tries to get up on her own without help. On 11/5/19 at approximately 2:51 PM, an interview was conducted with LPN 3 Licensed Practical Nurse 3). LPN 3 stated that facility nurses have helped resident 38 from falling by using a tab alarm, fall mat next to her bed, checking in on her frequently and having resident 38 sit in a mobile recliner near the Nurse's Desk. LPN 3 stated that after an unwitnessed fall, the resident is assessed, neuro checks are started and a post fall assessment is completed by nursing. LPN 3 stated that the DON updates the resident's Care Plan. On 11/5/19 at approximately 3:06 PM, the Director of Nursing (DON) was interviewed. The DON described the facility's process following a resident fall. The DON stated that a nurse assesses the resident for injuries and completes a post-fall assessment. The resident's physician is notified through secure communication in Point Click Care (PCC), the facility's electronic medical record system. The DON stated that an Interdisciplinary Team (IDT) will meet together the next day to review the event and identify a root cause for the fall. New fall prevention interventions are determined by the IDT. The DON then adds the new fall prevention interventions to the resident's Care Plan. On 11/5/19 resident 38's medical record was reviewed. Resident 38 had the following nine documented falls from admission, 1/17/19 through 10/8/19: a. On 3/28/19 at 3:59 PM, the following SBAR (Situation, Background, Assessment, and Review and notify) note was documented. Situation: Unwitnessed fall- neuro checks began Background: Unsteady gate. Pt (Patient) wanders throughout halls frequently. Assessment: Pt found on floor sitting upright in a doorway. No injuries noted. Redness to B (both) cheeks noted however pt denies hitting her face. Review and notify: Hospice & DON notified. b. On 3/31/19 at 3:26 AM, the following SBAR note was documented. Situation: Unwitnessed fall Background: Pt has unsteady gait, is forgetful. Assessment: Pt was found sitting down by her bedside. Her roommate call to notify us that she fell. Pt states she was trying to sit on her bed but she missed, sat sideways on the edge of the bed and slid to the floor. Review and notify: Hospice notified. Left msg (message) 2230 (10:30 PM) c. On 4/24/19 at 10:49 PM, the following SBAR note was documented. Situation: Unwitnessed fall Background: Pt walking around room wearing nylon knee highs. She lost her balance and fell. Assessment: ST (skin tear) to r elbow. Pt denies pain. Review and notify: Pt educated on importance of wearing shoes when walking around room. [Family member] notified 4/24/19 2145 (9:45 PM). [Hospice] notified 4/24/19 2145. d. On 5/29/19 at 5:41 PM, the following SBAR note was documented. Situation: Unwitnessed fall Background: Ambulating in room & (and) fell. Hx (History) of falls. Pt does not ask for assistance. Education provided. Assessment: No injuries noted. Vitals [signs] stable. Pt denies pain/injuries. Review and notify: Hospice, DON notified. [Family member] notified. e. On 6/17/19 at 7:46 PM, the following SBAR note was documented. Situation: Unwitnessed fall Background: Pt found sitting on the floor by her bed. She stated she was trying to transfer herself into the bed and fell. Assessment: Neuro checks started. VS (vital signs) stable, no injuries noted at this time. Will continue to monitor. Review and notify: DON, hospice nurse notified. Family notified by hospice nurse. f. On 7/13/19 at 10:52 AM, the following SBAR note was documented. Situation: Unwitnessed fall Background: metabolic encephalopathy Assessment: No injuries. Vitals [signs] stable. Neuros intact. Rst (Resident) was found sitting up right against a closed bathroom door on her buttocks. Rst was unable to state what she wanted to do but she had a pair of pants in her hand. Review and notify: Hospice notified. g. On 8/4/19 at 6:30 PM, the following SBAR note was documented. Situation: Unwitnessed fall Background: HX of falls Assessment: No obvious injury, resident denies pain; moves all extremities as prior to fall Review and notify: not to be left alone in her w/c; Notified DON/ADON (Assistant Director of nursing) via secure conversation at 1936pm (7:36 PM); Hospice nurse notified by phone at 1938 (7:38 PM). [Hospice Nurse] said she would notify the MD (physician) from Hospice; Family [notified] by phone at 1943 (7:43 PM) h. On 8/30/19 at 4:38 PM, the following Nurses Note was documented. pt found on floor, she remembers attempting to get to her shoes, pt was assisted to her w/c (wheelchair) and assessed, no apparent injury noted, Hospice notified, hospice will notify family, neuros [checks] initiated, d/c (discontinued) by hospice at 1900 (7:00 PM) i. On 10/8/19 at 7:50 PM, an Event Initial Note was documented. Unwitnessed fall Date of Event: 10/8/19 Time of event : 1950 (7:50 PM) Detailed description of event (how, when, where, vitals, symptoms): Resident said that she wanted to get into her chair which is at bedside. She slipped to the floor and is found on her left side by the CNA 1. She is alert and talkative. BP (Blood Pressure): 106/85 HR (Heart Rate): 95 RR (Respiratory Rate): 20 RA (Room Air) O2 sat (saturation): 93%, TEMP (Temperature): 98.1 She has a small skin tear to the lateral left wrist. Patients description of event: She said that she wanted to get into her chair (which is at bedside) and fell. MD Notification (Date, Time, Method of communication): [Hospice] has a busy signal. Will attempt later. DON and ADON notified at 2005 (8.05 PM) Responsible Party Notification (Date, Time): [Family member], notified at 2000 (8:00 PM); 10/8/19 New Interventions initiated: She already has a low bed, fall alarm. floor mats and frequent checks in place. If Fall note-injury, how patient was found, environment, footwear, last toileted, FSBS (finger stick blood sugar) if diabetic: She was found propped up on her left side. After eval (evaluation), she was lifted into her chair for further eval. She has no change in ROM (Range of Motion) of extremities. She remains alert and talkative. She has no footwear on at this time. The floor area was not cluttered, she is weak. She had been put to bed about an hour prior to this event. Neuro checks are started. An Interdisciplinary Team Meeting, that included the Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Social Worker (SW), and the Director of Rehab (DOR) were held and documented following each fall except for the fall on 8/30/19. Resident 38's Fall Care Plan was initially initiated on 2/20/19 with the following FOCUS area: [Resident 38] is at risk for falls/injuries r/t (related to) cognitive impairment, fall history, gait and balance, use of antidepressants, use of antipsychotic drugs, visual impairment, generalized weakness, poor safety awareness. The initial Fall Care Plan included the following GOAL initiated 2/20/19: Safety measures will be maintained to prevent or lessen any injury from fall. The initial Fall Care Plan on 2/20/19 included the following fall prevention interventions: a. Assess for any adaptive equipment needed. Encourage use if necessary. b. Do not rush resident; allow adequate time for ambulation to the bathroom and in hallway instruct and assist resident to rise and change positions slowly in order to reduce dizziness associated with postural hypotension perform actions to improve cardiac output in order to improve cerebral blood flow and subsequently reduce dizziness, syncope, agitation, and confusion. RESOLVED 4/8/19 c. Encourage resident to wear non skid soles for shoes. RESOLVED 4/8/19 d. Ensure that lighting is adequate and lights are functioning, including night lights. RESOLVED 4/8/19 e. Ensure that the clothing does not cause tripping; and that rubber soled, heeled shoes or nonskid slippers are worn. RESOLVED 4/8/19 f. if resident is confused or irrational: reorient frequently to surroundings and necessity of adhering to safety precautions provide appropriate level of supervision. g. Implement measures to prevent falls: keep bed in low position with side rails up when client is in bed keep needed items within easy reach. h. Keep frequently used items within easy reach. i. Maintain regular toileting at set intervals and/or a continence program; provide easy access to urinals and bedpans. j. Monitor for any weakness or instability. Notify MD PRN. RESOLVED 4/8/19 On 4/8/19, an additional fall prevention intervention was added to the Fall Care Plan. k. Wander guard daily. RESOLVED 8/15/19 On 4/25/19, an additional fall prevention intervention was added to the Fall Care Plan. l. Remove pantyhose from Pts room. On 8/19/19, two additional fall prevention interventions were added to the Fall Care Plan. m. Use floor mats when in bed. n. Use personal or pressure sensor alarms when the resident is in a chair or bed. On 7/17/19, resident 38 was moved to a room closer to the Nurse's Desk. 2. Resident 50 was admitted to the facility on [DATE] with diagnoses which included a history of falls, left pubic fracture, lumbar vertebra fracture, sacrum fracture, rib fracture, left arm cellulitis, gait abnormality, type 2 diabetes mellitus, asthma, hypertension, dementia without behavioral disturbance, and major depressive disorder. On 11/4/19 resident 50 was observed in her bed without the fall mat in place on the floor next to the bed. On 11/5/19 resident 50 was observed in her bed without the fall mat in place on the floor next to the bed. On 11/5/19 resident 50's medical record was reviewed. Resident 50's medical record revealed the following falls: a. 3/15/19 with resident 50 being assessed as a moderate risk for falls. b. 3/18/19 with resident 50 being assessed as a moderate risk for falls. c. 3/21/19 with resident 50 being assessed as a moderate risk for falls. d. 3/26/19 with resident 50 being assessed as a high risk for falls. e. 4/17/19 with resident 50 being assessed as a high risk for falls. f. 5/2/19 with resident 50 being assessed as a high risk for falls. g. 5/13/19 with resident 50 being assessed as a high risk for falls. h. 7/18/19 with resident 50 being assessed as a moderate risk for falls. The medical record revealed that resident 50 sustained skin tears and bruising with the falls on 3/18/19 and 5/2/19. The care plan dated 4/8/19 for resident 50 revealed that [Resident 50] is at risk for injuries r/t recent history of falls on 3/15/19, 03/25 and 03/26 d/t (due to) balance problem and generalized weakness. actual fall 4/17/19-no injury Actual fall 5/2/19 no injury Actual fall 5/13/19-no injuries actual fall 7/18/19-no injuries The goal for resident 50 was Resident will be free from injury r/t falls at all times through next 90day review The interventions included Ambulate as resident is capable, Assure that lighthing (sic) is adequate, Be careful when getting a mostly immobile client up, Be sure to lock the bed and wheelchair and have sufficient personnel to protect client from falls, Call light close and answered promptly, Encourage use of non skid shoes and socks, Evaluate client's medications to determine whether medications increase the risk of falling; consult with physician regarding client's need for medication if appropriate, Instruct to call for assist with transfers, Monitor blood pressure if on hypertensive medications, Monitor resident for steadiness and balance, Monitor vitals, Place a fall-prone client in a room that is near the nurses' station. Such placement allows more frequent observation of the client. toileting q 2 hours for fall prevention. [NOTE: The medical record revealed that resident 50 did not have a care plan in place for her history of falls nor for her actual falls in the facility until 4/8/19. The care plan interventions were added at that time with the exception that resident 50 was to be toileted every 2 hours for fall prevention that was added on 4/26/19. The care plan revealed that the facility did not add an intervention after each fall in an attempt to prevent resident 50 from falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 38 sample residents, that the pharmacist did not report irregularities in the drug regimen review to the attending physician, the facility's Medical Director, and Director of Nursing. Irregularities include, but are not limited to, any medication when used without adequate monitoring or without adequate indications for its use. Specifically, the pharmacist did not report the irregularity of the use of antipsychotics and antidepressants for residents that did not have a diagnosis of a serious mental illness, and to residents with dementia. Resident identifiers: 25 and 50. Findings include: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included left pubic fracture, lumbar vertebra fracture, sacrum fracture, rib fracture, left arm cellulitis, gait abnormality, type 2 diabetes mellitus, asthma, hypertension, dementia without behavioral disturbance, and major depressive disorder. On 11/5/19 resident 50's medical record was reviewed. Physician's orders revealed that resident 50 was receiving Ziprasidone HCl Capsule 20 MG Give 20 mg by mouth two times a day related to UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE OTHER SPECIFIED MENTAL DISORDERS DUE TO KNOWN PHYSIOLOGICAL CONDITION. The PASRR (Preadmission Screening and Resident Review) Level I dated 6/11/19 revealed that resident 5's Level I screen indicates referral for Level II evaluation SMI (Serious Mental Illness) is not needed due to resident 5 not having a history of a serious mental illness. On 11/6/19 at 8:48 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the facility process for the psychotropic meetings was to include herself, the facility Assistant Director of Nursing (ADON), the facility Medical Director, the facility Social Service Director (SSW) and the facility pharmacist attend the psychotropic meeting. The facility DON stated that in the meeting, they would make sure that residents had an appropriate diagnoses for all psychotropic medications. The facility DON stated that she would look at resident 50's medical record for something from the facility Medical Director regarding a risk vs benefits. [NOTE: No additional information was provided by the facility DON.] On 11/6/19 at 12:15 PM, an interview was conducted with the facility SSW and the facility pharmacist. The facility pharmacist stated that there was some studies regarding the use of antipsychotics with Major Depressive Disorder and would forward the information. The facility pharmacist stated that because the antipsychotic was similar to the approved antipsychotics, that it was probably ok for resident 50 to take it. The facility SSW stated that she thought resident 50 had an approved diagnosis for the antipsychotic and that she had a PASRR level II for the use of the medication. According to the Nursing Drug Handbook by Wolters Kluwer, the black box warning revealed that In elderly patients with dementia-related psychosis, drug isn't indicated for use because of increased risk of death from CV events or infection. 2. Resident 25 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included anemia, septicemia, rheumatoid arthritis, osteoporosis, respiratory failure, malnutrition and anxiety. On 11/6/19 resident 25's medical record was reviewed. The facility pharmacist medication regimen review revealed a pharmacy recommendation that had been completed on 10/11/19 for a CBC (complete blood count), Ferritin and Iron levels since resident 25 had been started on Ferrous Sulfate for severe anemia. The medication regimen review revealed that the pharmacy recommendation had not been acted upon until 11/5/19, 25 days after the recommendation had been made. On 11/6/19 at 8:56 AM, an interview was conducted with the facility DON. The facility DON stated that she had been on vacation and when she had returned, she asked the facility pharmacist where her recommendations were, and that he had answered that he had sent them to her. The facility DON reminded him that she had been on vacation. The facility DON stated that the facility pharmacist responded that he had forgot and would resend the recommendations. The facility DON stated that she did not receive the recommendations until 10/31/19. The facility DON stated that the ADON (Assistant Director of Nursing) was to take over for her while she was on vacation and did not know why the recommendations had not been followed up on.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, staff were observed in the food prep area without a hairnet. Resident identifier: 9. Findings include: 1. On 11/4/19 at 11:40 AM, an observation was made of Dietary Tech (DT) 1 with her hair up in a bun on top of her head and hair was hanging down on her neck and around her face. DT 1 was observed with the hair net only covering her bun, the rest of her hair uncovered. DT 1 was observed to go in and out of the kitchen with uncovered hair six times. On 11/5/19 at 7:34 AM, an observation was made of the Certified Nursing Assistant (CNA) Coordinator helping to serve breakfast. The CNA Coordinator was observed not wearing a hair net. The CNA Coordinator was observed to go into the kitchen twice. On 11/4/19 at 4:45 AM, an observation was made of the Speech Language Pathologist (SLP) go into the kitchen to grab food for a resident. The SLP had her hair down and was not wearing a hair net. On 11/4/19 at 2:01 PM, an interview was conducted with resident 9. Resident 9 stated that the staff didn't wear hair nets in the kitchen and that really bothered him. Resident 9 stated that staff not wearing hair nets had been brought up in resident council, stated that there had been no change. On 11/6/19 the Resident Council Meeting minutes were reviewed for 10/28/19. A dietary concern brought up was documented as staff not wearing hair nets. On 11/6/19 at 1:16 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that staff should wear hair nets at all times in the kitchen and when the line was served. The DM stated that the only exceptions were if the staff member was bald. The DM stated that the proper way to wear a hair net was for it to cover all of the hair, with no loose hair hanging out. The DM stated that the risk of not wearing a hair net was that hair could end up in the food.