**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 22 sampled resident, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, there was no documentation regarding a resident experiencing a change in condition prior to passing away. Resident identifier: 30. Findings included: Resident 30 was admitted to the facility on [DATE] and passed away on 11/4/24 with diagnoses which included diverticulitis, need for assistance with personal care, muscle wasting, heart failure, chronic obstructive pulmonary disease and chronic respiratory failure. Resident 30's medical record was reviewed 1/6/25 through 1/8/25. A physician's note dated 11/3/24 revealed resident 30 had a history of diverticulosis. The assessment documented that resident 30's chest was clear, cardiac was regular, abdomen was benign and vital signs were stable. The assessment and plan further revealed On going support care, medication management. Antibiotics until course is complete. She has shown overall improvement. Continue supportive care until stable for discharge. A nursing progress note 11/3/24 at 10:28 AM from Registered Nurse (RN) 1 revealed that resident was alert and oriented to person, place and time. Resident 30 had clear speech and was able to understand and was understood when she was talked to. Resident 30 did not have shortness of breath, posterior middle lobe and left posterior upper lobe were diminished on auscultation. Resident 30's abdomen was flat, non-tender with bowel sounds present x 4. Resident 30's skin was clean, dry and intact. Resident 30 was able to move all extremities with no limited range of motion. Resident and responsible party were aware of diagnosis and plan of care. A Brief Interview of Mental Status (BIMS) was completed on 11/3/24 at 1:05 PM. Resident 30's BIMS was 15 which indicated she was cognitively intact. Resident 30's November 2024 Medication Administration Record (MAR) was reviewed and revealed Melatonin 5 miligrams (mg), and Pramipexole Dihydrocholide 0.25 mg were administered at 8:00 PM. Resident 30 was administered Lorazepam 0.5mg tablet on 11/3/24 at 7:22 PM and on 11/4/24 at 1:51 AM. The next nursing progress note from RN 2 revealed on 11/4/24 at 4:40 AM, patient's vitals ceased this morning around 3:30am. daughter present at bedside. Pt [patient] will be released to mortuary. On 1/7/25 at 2:19 PM, a phone interview was conducted with RN 2. RN 2 stated if a resident had a change in condition, then she assessed the resident to determine what the change was. RN 2 stated if the CNA told her a resident had a change in condition, then she assessed the resident. RN 2 stated if a family member noticed a resident's change in condition, then she asked what the resident's baseline was and ask what was going on with the resident. RN 2 stated depending on what the change in condition was, she would provide immediate care and contact the physician for further direction. RN 2 stated if there was an emergency, then she called the physician and the resident was sent to the hospital. RN 2 stated if the family was concerned about a change in condition, she provided all the options for the resident and family. RN 2 stated she was unable to remember resident 30. RN 2 stated if resident 30's death was unexpected, then would have documented more. RN 2 stated she thought resident 30's death was expected. On 1/7/25 at 2:44 PM, an interview was conducted with RN 1. RN 1 stated if a resident experienced a change in condition, then she assessed the resident and notified the physician. RN 1 stated resident 30 was able to answer questions and was declining during her shift but had not experienced a change in condition. RN 1 stated after resident 30 had passed away she learned that resident 30 had called her family to tell them she was going to die. RN 1 stated she learned resident 30 was out of it during the night shift, woke up for a little while and then passed away. RN 1 stated she did not document a change in condition because resident 30 did not experience one while she was on shift on 11/3/24 and her shift ended about 6:00 PM. On 1/7/25 at 3:11 PM, a follow-up interview was conducted with RN 2. RN 2 stated she looked through resident 30's medical record and remembered resident 30's daughter was at the bedside. RN 2 stated she came to work and was told during the nurse to nurse report that resident 30 was actively passing away. RN 2 stated she remembered resident 30's change was sudden. RN 2 stated resident 30 had stopped taking her medications and was unresponsive when she came on for shift. RN 2 stated resident 30 was getting anti-anxiety medications. RN 2 stated resident 30's family member was at her bedside and she told the nurse that resident 30 did not want any interventions and wanted to die peacefully. RN 2 stated she provided resident 30 some Ativan because she was anxious. RN 2 stated resident 30 woke up about 2:00 AM and was talking with her daughter. RN 2 stated she asked for her sleeping medication about an hour later and was administered the medication and passed away. RN 2 stated she worked with resident 30 a few days before and resident 30 was having trouble breathing since admission. RN 2 stated nurses should document if someone was actively passing away. RN 2 stated she was in the room often checking on resident 30 throughout the night. On 1/7/25 at 2:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident experienced a change in condition, family were notified, and the physician was notified for treatment options. The DON stated if there was a significant change in condition, the resident was transported to the hospital. The DON stated for resident 30 the nursing progress notes indicated resident 30 was doing well and there was no documentation of a change in condition. The DON stated in her notes that were not in the medical record, on 11/3/24 a nebulizer was started, Lasix was started and the family was requesting hospice. The DON stated according to physician's orders the nebulizer was started on 10/31/24 and Lasix was started on 11/3/24. The DON stated Lorazepam was ordered on 11/3/24 and there should have been documentation regarding why the anti-anxiety was ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident was admitted with pressure ulcers [PU] and treatments were not provided according to physician orders. In addition, physician's orders were not the same as the wound clinic orders. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included acute osteomyelitis of right ankle and foot, diastolic heart failure, diabetes mellitus, pressure ulcer of right heel stage 3, severe-protein calorie malnutrition, acute respiratory failure with hypoxia, and severe sepsis. On 1/6/25 at 2:10 PM, an interview was conducted with resident 9. Resident 9 stated he had sores on his feet. Resident 9 was observed to have both feet wrapped with black colored coban. There were no dates on the dressings. The dressings were from the toes to the ankles. The facility provided a Matrix which revealed resident 9 had stage 3 pressure ulcers. Resident 9's medical record was reviewed 1/6/25 through 1/8/25. A significant change Minimum Data Set (MDS) dated [DATE] revealed resident 9 had one or more unhealed pressure ulcers/injuries that were a stage 3 and present upon admission. In addition, resident 83 had 4 venous and arterial ulcers. A care plan dated 11/20/24 revealed Resident with risk for skin impairment - Decreased mobility, Skin impairment on admit, Previous amputation of all 5 toes to R [right] foot, Surgical wound to bilateral feet .R and L [left] feet diabetic ulcers, Stage 3 PU to bilateral heels, . The goals identified were Resident will have no new skin break down or PU TNR [through next review] and Residents PU will show signs of healing TNR. Interventions included Enhanced Barrier Precautions (EBP) during high-contact care activities; Monitor/document location, size and treatment of skin injury weekly. Report abnormalities, s/s [signs and symptoms] of infection to medical provider; Use caution during transfers and bed mobility; Treatment as ordered; Encourage and assist with frequent repositioning; Preventative skin care; Float heels as indicated; Skin assessment weekly and PRN [as needed]; Supplements as indicated; Notify MD [Medical Doctor] with concerns; Resident is currently being treated for an infection Osteomyelitis to R foot with Streptococcus Mitis, MSSA [methicillin-susceptible Staphylococcus aureus] bacteremia; Resident will be free from adverse side effects of antibiotic therapy TNR; Observe for possible side effects of antibiotics- such as diarrhea, nausea, vomiting, anorexia, hypersensitivity/allergic reaction. Notify provider; and Report new or worsening symptoms to provider. A Skin and wound evaluation completed on 11/27/24 revealed Multiple wounds to both feet present on admission. [Wound care clinic] Wound Care will follow wounds as per resident and facility request. See notes under miscellaneous tab for wound and visit details. The evaluation revealed resident 9 had a stage 3: Full- thickness skin loss to the Left lateral mid foot. On 11/27/24, there was an initial consult and evaluation from the wound clinic. The onset of the wound was October 2024 with an unknown date. The consult revealed that resident 9 was [AGE] years old with a history of chronic foot wounds. In addition, resident 9 liked to walk and be active but did not feel his feet and was unaware the wounds were getting worse. Resident 9 reported that he got sick with sepsis and that was when he went for care for his general health and they identified his feet. A surgical debridement on his feet was done and he was noted to have osteomyelitis and was administered intravenous antibiotics. Resident 9 had several wounds on both feet. The measurements for the wounds revealed the following: a. Right heel medial - 2.5 x 1.3 x 0.2 centimeters (cm) b. Right planter surface - 3.2 x 2.4 x 1.0 cm c. Left planter surface -1.6 x 1.3 x 2.0 cm d. Left anterior surface - 3.9 x 3.6 x 0.2 cm e. Left lateral aspect - 3.3 x 3.4 x 0.2 cm. The treatments revealed resident 9 had a stage 3 pressure injury to the right heel which was chronic and currently had osteomyelitis. There was another pressure injury to the left heel which was a stage 3 which was a chronic wound. The physician's ordered wound treatments from the visit on 11/27/24 were: a. Right heel medial - remove old dressing, cleanse wound with cleanser, cover wound and periwound with iodine and iodosorb prelase cover with alginate wrap dressing in rolled gauze and coban. b. Right planter surface - removed old dressing, cleanse wound with wound cleanser, cover wound and periwound with iodine and iodosorb, cover with alginate wrap dressing in rolled gauze and coban. c. Left [NAME] surface: removed old dressing, cleanse wound with wound cleanser, cover wound and periwound with iodine and iodosorb, pack with packing tape, cover with alginate, wrap dressing in rolled gauze and coban. d. Left anterior surface: removed old dressing, cleanse wound with wound cleanser, cover wound and periwound with iodine and iodosorb, cover with alginate, wrap dressing in rolled gauze and coban. e. Left lateral aspect: Removed old dressing, cleanse wound with wound cleanser, cover wound and periwound with iodine and iodosorb, cover with alginate, wrap dressing in rolled gauze and coban. The consult further revealed the facility should change the dressing 2 times per week and as needed and the wound clinic would visit resident 9 weekly on Wednesdays. The consults were reviewed and revealed the same treatment orders. On 12/4/24 the wounds were progressing since the last visit and resident continued on antibiotics. The measurements for the wound were as follows: a. Right heel medial - 2.0 x 1.4 x 0.2 cm b. Right planter surface - 3.7 x 3.5 x 1.0 cm c. Left planter surface - 1.0 x 1.2 x 1.0 cm d. Left anterior surface - 2.4 x 3.4 x 0.1 cm e. Left lateral aspect - 3.2 x 2.8. 0.2 cm The wound clinic consult dated 12/11/24 revealed the following measurements: a. Right heel medial - 1.7 x 0.9 x 0.2 cm b. Right planter surface - 2.0 x 2.3 x 0.5 cm c. Left planter surface - 1.0 x 1.0 x 1.0 cm d. Left anterior surface - 5.3 x 4.0 x 0.1 cm e. Left lateral aspect - 3.3 x 3.2 x 0.2 cm. It should be noted resident 9 was discharged to the hospital 12/13/24 through 12/20/24. Resident 9 was seen by the wound clinic consult on 12/26/24. There were no changes to the orders. Resident 9 was seen by the wound clinic on 1/2/24. The notes revealed resident 9 was off his intravenous antibiotics and he felt like his wounds were healing and feet were looking better. The measurements were: a. Right heel medial - 0.5 x 0.5 x 0.1 cm b. Right planter surface - 2.4 x 2.2 x 0.3 cm c. Left planter surface - 1.0 x 1.0 x 1.0 cm d. Left anterior surface - 3.5 x 4.5 x 0.1 cm e. Left lateral aspect - 2.8 x 3.1 x 0.2 cm. Physician order's dated 11/20/24 and discontinued on 12/15/24 were to encourage/assist with frequent positioning and floating heels while in bed every shift. Another order with the same dates revealed bilateral feet off-loaded at all times, float with pillows when in bed, use off-loading boots when in wheelchair every shift for multiple diabetic ulcers to both feet. The order was restarted on 12/20/24 when resident 9 was readmitted from the hospital. According to the resident 9's Treatment Administration Record the following treatments were provided: a. On 11/20/24 and discontinued on 12/15/24 revealed, Left foot: 1st metatarsal plantar wound cleanse with NS [normal saline], pack with packing strip, apply iodosorb and cover with 2x2 gauze dressing. Apply iodosorb to all other wounds and betadine to scabs on foot/toes. Cover wound between 1st and 2nd toes and plantar surgical wound with calcium alginate. Cover entire foot with large abdominal pad, wrap with gauze then ace wrap. Change on shower days Monday, Wednesday and Friday (MWF) and as needed. Resident 9's dressings were changed on 11/25, 11/27, 11/29, 12/2, 12/4, 12/6, 12/9, 12/11 and 12/13. b. On 11/27/24 and discontinued on 12/15/24 revealed, Right foot: lateral wound- cleanse with NS, apply iodosorb then calcium alginate. Inner wound - cleanse with NS, calcium alginate. Iodosorb to all other scabs/wounds. Wrap entire foot with large abdominal pad, gauze and ace wrap. Change on shower days MWF and PRN. Resident 9's dressings were changed on 11/29, 12/2, 12/4, 12/6, 12/9, 12/13. c. On 12/20/24 and discontinued on 12/24/24 revealed, skin: Right plantar foot, Right medial heel, Left lateral plantar foot, Left anterior ankle: cleanse with puracyn apply iodoflex to wounds and cover anterior ankle with bordered gauze dressing. Other wounds cover with ABD pad and kerlix. change every 3 days. Resident 9's dressing was not changed during from 12/20/24 through 12/24/24. d. On 12/24/24 and discontinued on 1/3/25 revealed, skin: Right plantar foot, Right medial heel, Left lateral plantar foot, Left anterior ankle: cleanse with NS apply iodosorb to wounds and cover anterior ankle with bordered gauze dressing. other wounds cover with ABD pad and kerlix. Change every 3 days. Resident 9's dressing was changed on 12/26/24 and 1/2/25. e. On 12/20/24 and discontinued on 12/24/24 revealed skin: Left medial plantar foot: cleanse with puracyn and apply 1 piece of algidex 1/4 in packing cover with ABD and kerlix, change every 3 days every shift. Resident 9's dressing was not changed. f. On 12/24/24 through the current revealed, skin: Left medial plantar foot: cleanse with NS and apply 1 piece of oil emulsion 1/4 inch packing cover with ABD and kerlix, change every 3 days every shift. Resident 9's dressing was changed on 12/25, 12/26 and 1/2/25. g. On 12/24/24 through 1/3/25 revealed, skin: Left dorsal foot- cleanse with NS, gauze throughout 1,2,3 toes cover with ABD pad and kerlix change every 3 days every shift. Resident 9 had a dressing change done 12/25, 12/26 and 1/2/25. h. A current treatment that started on 1/3/25 revealed skin: Left foot- cleanse each wound with separate NS-soaked gauze. 1) plantar wound-iodosorb in wound, betadine peri wound, pack with packing tape, cover with alginate. 2) anterior and lateral wounds iodosorb and calcium alginate to wound beds and betadine peri wounds. Wrap foot wi [sic] Change on shower days and PRN. Every shift. Resident 9's dressing had not been changed. i. A current treatment that started on 1/4/25 revealed, skin: Right plantar foot, Right medial heel cleanse with NS, apply iodosorb to wound beds, peri wound with betadine, cover with alginate and wrap foot with rolled gauze and coban. Change on shower days and PRN. Every shift for wounds. Resident 9's dressing had not been changed. On 1/8/25 at 10:43 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a resident was admitted with a pressure ulcer, she would look to see if there were physician's order from the hospital for treatment. RN 1 stated when a resident was admitted the night shift nurse completed a skin check and let the Wound Nurse (WN) know if there were wounds. RN 1 stated the WN then obtained orders from the physician for treatment. RN 1 stated there was a wound clinic that came to the facility to treat wounds. RN 1 stated the wound clinic communicated with the WN and the WN added the orders to the medical record. RN 1 stated the +/- on the TAR was to indicate if there were any signs or symptoms of infection. RN 1 stated according to the TAR resident 9's left foot dressing was changed on 1/2/25. RN 1 stated she would look at the wound dressing to see the date to know if the dressing needed to be changed. RN 1 stated when a dressing was changed she wrote the date on the dressing. On 1/8/25 at 10:50 AM, an interview and observation was made of resident 9. Resident 9 stated a wound specialist changed his dressing on his feet last week. Resident 9 stated the wound specialist came about weekly to see him and look at his wounds. Resident 9 stated he did not have set shower days because sometimes he did not feel like showering. Resident 9 stated he did not feel like showering today because he was not feeling good and did not want a shower. Resident 9's bandages were observed to be covered in black coban from the ankle to the base of the toes with no date. On 1/8/25 at 10:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated wound care was provided when it alerted in the residents medical record. LPN 1 stated if a resident was admitted with a wound, the physician provided orders and how often to change it. LPN 1 stated the +/- was to monitor for signs and symptoms of infection. LPN 1 stated the resident's medical record showed the nurses when the last time a bandage was changed. LPN 1 stated it looked like the last time the left foot was changed was on 1/2/24. LPN 1 stated the physician order revealed his bandage should be changed on shower days and as needed. LPN 1 stated she was not sure what days resident 9 was showered. LPN 1 was able to locate a form with shower days and resident 9's were Monday, Wednesday and Friday. LPN 1 stated the right foot was to be changed on shower days and as needed. LPN 1 stated the left foot was to be changed every 3 days. LPN 1 stated she was not sure the last time the bandage was changed and would look at the dressing for a date. On 1/8/25 at 11:09 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was admitted to the facility with a pressure ulcer, the physician provided treatment orders. The DON stated the night shift nurse completed a skin check and determined if there were treatments needed for wounds. The DON stated the WN looked at the residents wounds the next day or 2 to determine if the treatment needed to be changed. The DON stated the facility had a wound clinic that came to the facility to provide treatments weekly. The DON stated if there was a concern about a skin area or if the WN was wondering if the treatment was appropriate then the wound clinic was involved. The DON stated resident 9's dressing should be changed 2x per week according to the Wound Clinic but the orders were for every 3 days for the left foot and shower days for the right foot. The DON stated resident 9 should not have gone 5 days without a dressing change from 12/26/24 through 1/2/25 and 1/2/25 through 1/8/25. The DON stated that the nurse should have signed the bottom of the Wound Clinic note to show the orders had been put into the computer. The DON stated the +/- was to indicate if there are any s/s of infection. On 1/8/25 at 12:03 PM, an interview was conducted with WN. The WN stated the night nurse extensively document any skin issues on a form after admission. The WN stated the forms were provided to her. The WN stated the nurses entered physician's orders into the medical record. The WN stated if the wound needed extensive care beyond nursing, then the Wound Clinic was involved. The WN stated the Wound clinic did weekly round and she took notes of what needed to be changed with physician's orders. The WN stated wounds that were a stage 3 or higher or chronic vascular wounds were referred to the Wound clinic. The WN stated resident 9 was admitted with an extensive history of diabetic ulcers. The WN stated resident 9 told her he had been followed by wound care until about 2018 and he went a few years without wounds. The WN stated resident 9 told her that he started to develop sores prior to admission to the hospital. The WN stated resident 9 had osteomyelitis on one foot and an abscess to the other foot. The WN stated resident 9 had surgery on his wounds prior to admission and he was referred to the wound clinic upon admission. The WN stated resident 9's wounds were slowly improving. The WN stated the current orders were to cleanse each wound with NS soaked gauze, iodosorb to wound beds, betadine around the wound for the left foot every 3 days. The WN stated for the right heal and right planter foot alginate was applied and wrapping with gauze on shower days and as needed. The WN stated the order revealed for the nurse to document if the wound was checked or changed. The WN stated on the TAR the nurses were able to look and see when the dressing had been changed last. The WN stated the dressing for the right foot should have been changed Monday but it was documented the dressing was checked and not changed. The WN stated there should be a progress note if the dressing was not changed. The WN stated there was no nurses note on 1/6/25. The WN stated dressings for both feed were changed except on 12/25/24, 12/26/24 and 1/2/25. The WN stated the Wound Clinic knew the staff changed dressing on residents shower days, so she was not sure why they documented 2 times per week. The WN stated she was not sure when resident 9's shower days were so she entered the physician's order and then the nurses were to put in which days to change the dressing. The WN stated she had a verbal discussion with the Wound Nurse Practitioner (NP) and then notes were provided a few days later, so maybe the Wound NP did not document what had been decided during the appointment. A Pressure Injury Prevention and Management policy and procedures dated 5/23/23 revealed: Policy: This facility is committed to prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries. Definitions: 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.' Policy Explanation and Compliance Guidelines: 1. There are multiple terms used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. For purposes of this policy, pressure injury, as the current standard terminology, will be used. 2. The facility shall establish and utilize a systematic approach for pressure injury preventions and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurse will conduct a Braden pressure injury risk assessment, on all resident upon admission/re-admission, then quarterly or whenever the resident's condition changes significantly. b. The tool will be used in conjunction with other risk factors not captured by the risk assessment. Examples of risk include. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. c. Evidence-based interventions for prevention will be implement [sic] for all residents who are assessed at risk or who have a pressure injury present. d. Evidence-based treatment in accordance with current standards of practice will be provided for all residents who have a pressure injury present. e. The goals and preferences of the residents and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring a. The DON or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at lease weekly, and document a summary of findings in the medical record. b. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications.as needed c. The DON will review each pressure injury that develops in the facility. Findings will be reported in the monthly QAA [Quality Assessment and Assurance] Committee Meeting. d. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule, and as needed when actual or potential problems are identified. 6. Modifications of Interventions a. Any changes to the facility's pressure injury prevention and management process will be communicated to relevant staff in a timely manner. b. Interventions on the resident's plan of care will be modified as needed. Considerations for needed modifications include:.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 22 sampled resident, the facility did not ensure that pain management was provided to residents who required services consistent with professional standards of practice and the comprehensive person-centered care plan and the resident's goals and preferences. Specifically, a resident complained of uncontrolled pain and the facility had not reassessed her pain. Resident identifier: 83. Findings include: Resident 83 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of greater trochanter of right femur, pain, need for assistance with personal care, diabetes mellitus, fibromyalgia, depression, anxiety and heart failure. On 1/6/25 at 12:13 PM, an interview was conducted with resident 83. Resident 83 stated she had been at the facility since before Christmas and was experiencing pain in the right leg. Resident 83 stated she had lots and lots of pain in the leg and Doesn't like to have pain in the leg and she Hates it. Resident 83 stated she broke her hip and was unable to have surgical repair but was participating in therapy. Resident 83 stated her back was bothering her. Resident 83 her back had been bothering her for a long time prior to admission. Resident 83 stated she was unable to find anyway to take the pain away in her back except when was receiving shots. Resident 83 stated she had not had shots in her back for about 3 years. Resident 83 stated pain medication helped with the pain and she was able to get pain medication when she asked for it. Resident 83 stated she let her pain get to high and then it was hard to get on top of the pain. Resident 83 stated she had x-rays at a clinic today and her pain was really really high. Resident 83 stated she just could not keep on top of her pain. Resident 83 stated It just hurts and it hurts bad. Resident 83 stated he told staff she could sleep at night but she did not sleep at night because of the pain. Resident 83 stated she needed to do something about the pain. Resident 83 was observed to be repositioning and rubbing her right leg during the interview. Resident 83's medical record was reviewed 1/6/25 through 1/8/25. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 83 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. A pain interview was conducted with resident 83. Resident 83 had scheduled and as needed pain medication with no non-pharmacological interventions provided. Resident 83 stated she frequently had pain which frequently effected her sleep, frequently pain interfered with therapy and frequently interfered with day to day activities. Resident 83's pain intensity was a 10 out of 10. A care plan dated 12/17/24 revealed Resident has pain r/t [related to] R [right] femoral fx [fracture], fibromyalgia, muscle spasms, migraines, GERD [gastroesophageal reflux disease], ear wax build up. The goal was Resident will verbalize adequate pain relief or ability to cope with incompletely relieved pain TNR [through next review]. Interventions included Notify MD [Medical Doctor] with concerns of new or worsening pain; Offer and assist with non-pharmacological interventions such as: repositioning, offer food/fluids, deep breathing, diversional activities; Pain medications as ordered/ Observe for effectiveness; and Treatments as ordered. Resident 83's physician's orders revealed: a. On 12/17/24 and discontinued on 12/22/24 revealed Hydrocodone-Acetaminophen Oral 10-325 milligrams (MG) every 6 hours as needed for pain. Pain scores were 6 to 8. b. On 12/17/24 and discontinued on 12/22/24 revealed Hydrocodone-Acetaminophen Oral 5-325 MG every 6 hours as needed for moderate pain. c. A current physician's order started on 12/22/24 revealed Hydrocodone-Acetaminophen Oral 5-325 mg every 6 hours as needed for moderate pain. d. A current physician's order dated 12/22/24 revealed Hydrocodone-Acetaminophen oral 5-325 mg 2 tablets every 6 hours. Resident 83's progress notes revealed the following: a. On 12/17/24 at 3:25 PM, .Pain: Pain Issue: #001: New. Location: Right hip. Pain score: 8. Frequency: Multiple times a day. Indicators of pain: Vocal complaints of pain. b. On 12/17/24 at 10:27 PM, .Pain: Indicators of pain: Facial expressions. Indicators of pain: Vocal complaints of pain. Indicators of pain: Non-verbal sounds. Pain Issue: #001: Changed. Location: Right hip. Pain score: 3. Frequency: Multiple times a day. PRN medication provided. See MAR [Medication Administration Record] for details. c. On 12/18/24 at 8:55 PM, .Pain: Indicators of pain: Vocal complaints of pain. Pain Issue: #001: Resolved. Location: Right hip. Pain score: 3. Frequency: Multiple times a day. PRN medication provided. See MAR for details. #002: New. Pain score: 8. Sharp. d. On 12/19/24 at 12:53 PM, .Pain: Indicators of pain: Facial expressions. Indicators of pain: Non-verbal sounds. Indicators of pain: Vocal complaints of pain. Pain Issue:#001: Resolved. #002: New. Location: Right hip. Pain score: 7. Sharp. Aching. Frequency: Multiple times a day. Distraction techniques utilized. Resident position changed. Relaxation techniques encouraged. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. e. On 12/20/24 2:42 PM, . Pain: Pain Issue: #001: Needs Review. Location: Right hip. Pain score: 2. Sharp. Aching. Frequency: Multiple times a day. Distraction techniques utilized. Relaxation techniques encouraged. Resident position changed. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. f. On 12/28/24 at 9:47 AM, .Pain: Pain Issue: #001: No Change. Location: Right hip. Pain score: 4. Sharp. Aching. Frequency: Multiple times a day. Distraction techniques utilized. Resident position changed. Relaxation techniques encouraged. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. #002: No Change. Location: Generalized. Pain score: 6. Aching. Stiffness. Frequency: Daily. Resident position changed. Relaxation techniques encouraged. Non-medication interventions provided relief. PRN medication provided. See MAR for details. g. On 12/29/24 at 9:50 AM, .Pain: Pain Issue: #001: No Change. Location: Right hip. Pain score: 4. Aching. Sharp. Frequency: Multiple times a day. Distraction techniques utilized. Resident position changed. Relaxation techniques encouraged. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. #002: No Change. Location: Generalized. Pain score: 6. Stiffness. Aching. Frequency: Daily. Resident position changed. Relaxation techniques encouraged. Non-medication interventions provided relief. PRN medication provided. See MAR for details. h. On 1/3/25 at 9:35 AM, .Pain: Pain Issue: #001: No Change. Location: Right hip. Pain score: 4. Sharp. Aching. Frequency: Multiple times a day. Distraction techniques utilized. Relaxation techniques encouraged. Resident position changed. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. #002: No Change. Location: Generalized. Pain score: 6. Stiffness. Aching. Frequency: Daily. Relaxation techniques encouraged. Resident position changed. Non-medication interventions provided relief. PRN medication provided. See MAR for details. i. On 1/4/25 at 10:13 AM, .Pain: Pain Issue: #001: No change. Location: Right hip. Pain score: 4. Aching. Sharp. Frequency: Multiple times a day. Distraction techniques utilized. Relaxation techniques encouraged. Resident position changed. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. #002: No Change. Location: Generalized. Pain score: 6. Stiffness. Aching. Frequency: Daily. Resident position changed. Relaxation techniques encouraged. Non-medication interventions provided relief. PRN medication provided. See MAR for details. j. On 1/5/25 at 12:29 PM, .Pain: Pain Issue: #001: No Change. Location: Right hip. Pain score: 4. Sharp. Aching. Frequency: Multiple times a day. Relaxation techniques encouraged. Distraction techniques utilized. Resident position changed. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. #002: No Change. Location: Generalized. Pain score: 6. Aching. Stiffness. Frequency: Daily. Relaxation techniques encouraged. Resident position changed. Non-medication interventions provided relief. PRN medication provided. See MAR for details. k. On 1/6/25 at 10:05 AM, .Pain: Pain Issue: #001: No Change. Location: Right hip. Pain score: 4. Aching. Sharp. Frequency: Multiple times a day. Distraction techniques utilized. Relaxation techniques encouraged. Resident position changed. Non-medication interventions did not provide relief. PRN medication provided. See MAR for details. #002: No Change. Location: Generalized. Pain score: 6. Aching. Stiffness. Frequency: Daily. Resident position changed. Relaxation techniques encouraged. Non-medication interventions provided relief. PRN medication provided. See MAR for details. Resident 83's December 2024 MAR was reviewed and revealed the following: a. Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed was administered with the following pain scores: i. On 12/17/24 at 8:25 PM was an 8 ii. On 12/18/24 at 4:49 AM was a 7, at 1:08 PM was a 7, and at 8:25 PM a 10 iii. On 12/19/24 at 7:13 AM was a 6 and at 2:06 PM was a 7 iv. On 12/20/24 at 7:34 AM was a 6 and at 5:39 PM was a 7 v. On 12/21/24 at 6:42 PM was an 8 vi. On 12/22/24 at 1:24 PM was a 6 and at 7:35 PM was a 7 b. Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed was administered with the following pain scores: i. On 12/23/24 at 1:33 PM was a 5 ii. On 12/24/24 at 8:21 AM was a 7 and at 9:27 PM was a 6 iii. On 12/25/24 at 7:54 AM was a 7 and at 8:58 PM was a 7 iv. On 12/31/24 at 1:59 PM was a 5 c. Hydrocodone-Acetaminophen 5-325 mg 2 tablets every 6 hours as needed was administered with the following pain scores: i. On 12/24/24 at 2:29 PM was an 8 ii. On 12/25/24 at 2:54 PM was a 7 iii. On 12/26/24 at 9:43 AM was a 7 and at 7:13 PM was an 8. iv. On 12/27/24 at 2:11 PM was an 8 and at 8:34 PM was 4. v. On 12/28/24 at 3:01 PM was a 9 and at 9:45 PM was a 5. vi. On 12/29/24 at 6:56 PM was a 5 vii. On 12/30/24 at 4:09 PM was a 7 viii. On 12/31/24 at 8:55 PM was a 6. Resident 83's January 2025 MAR was reviewed and revealed the following: a. Hydrocodone-Acetaminophen 5-325 MG every 6 hours as needed was administered with the following pain scores: i. On 1/1/25 at 7:22 PM was a 5. ii. On 1/2/25 at 1:30 AM was a 5, at 7:30 AM was a 5 b. Hydrocodone-Acetaminophen 5-325 mg 2 tablets every 6 hours as needed was administered with the following pain scores: i. On 1/3/24 at 8:38 AM was an 8 ii. On 1/4/25 at 3:13 PM was an 8 iii. On 1/5/25 at 2:09 AM was a 7, at 3:33 PM was an 8, and at 11:39 PM was an 8. iv. On 1/6/25 at 7:03 AM was an 8 and at 8:14 PM was an 8. v. On 1/7/25 at 12:29 PM was a 9. On 1/8/2 at 5 12:34 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated if a resident complained of pain, he would report it to the nurse. CNA 1 stated he had not worked with resident 83. On 1/8/25 at 1:28 PM, an interview was conducted with the Head CNA. The Head CNA stated if a resident complained of pain, she would ask the resident what was hurting. The Head CNA stated there was a report sheet provided to CNAs with information about resident diagnoses and pain. The Head CNA stated she would ask the resident what their level was and ask the resident what kind of medication they would like. The Head CNA stated she would then inform the nurse. The Head CNA stated she would also provided non-pharmacological interventions to residents like repositioning, heat, ice and other things. The Head CNA stated she was resident 83's CNA and resident 83 had not complained of pain but that morning she had complained of stiffness. The Head CNA stated resident 83 seamed a little confused that morning also. The Head CNA stated resident 83 complained of a little pain to her right leg but Nothing to terrible. The Head CNA stated resident 83 complained of being uncomfortable with movements like when she was getting dressed. The Head CNA stated she had not received report from the previous CNA that resident 83 had complained of pain. On 1/8/25 at 12:27 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident complained of pain, then she administered pain medication. LPN 1 stated if the resident said they were in pain, then she asked them about their pain. LPN 1 stated she would ask if the resident needed something for pain because they had a fall prior to admission or recently had surgery. LPN 1 stated she determined resident pain using the pain scale or she used facial expressions. LPN 1 stated resident 83 requested pain medication that morning at 6:38 AM. LPN 1 stated she had not administered any other pain medication to resident 83 that shift. LPN 1 stated resident 83 told her that the pain was radiating through her whole leg. LPN 1 stated after administering pain medication she did a follow up pain score and documented if it was effective or ineffective. LPN 1 stated resident 83's pain was a 7 before the pain medication and was a 4 at 7:30 AM. LPN 1 stated resident 83 was on as needed pain medication but no scheduled pain medications. On 1/8/25 at 1:39 PM, an interview was conducted with the Director of Nursing(DON). The DON stated nursing staff assessed residents' pain daily in the advantage skilled assessment. The DON stated she was not sure how to run a report for resident pain scores. The DON stated resident 83 was administered Hydrocodone in the last 7 days, 2-3 times per day. The DON stated she was not aware that that resident 83 was complaining of pain. The DON stated if pain score were high, she would expect nurses to notify the physician for an order for scheduled medication like Tylenol or Tramadol. The facility Pain- Clinical Protocol dated 2001 revealed the following: Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes reviewing known diagnoses and conditions that commonly cause pain;. b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments. 2. The nursing staff will assess each individual for pain upon admission to the facility, at quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, patter, and severity. a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 4. The nursing staff will identify an situation or interventions where an increase in the resident's pain my be anticipated . 5. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. 6. The nursing staff will identify and document residents with a history of opiate use disorder and those who are currently receiving medication assisted treatment for opiate dependence. Cause Identification 1. The physician will help identify causes of pain; . 2. The physician will help identify the extent to which underlying causes of pain can be addressed or reversed. 3. The physician will perform or order appropriate tests as needed to help clarify sources of pain. Treatment/Management 1. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. 2. The physician will order appropriate non-pharmacologic and medication interventions to address individual's pain. a. 3. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions. 4. If the physician determines that opiod medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. 5. Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 2. The staff will evaluate and report the resident/patients use of standing and PRN analgesics. 3. Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions that exacerbate pain, consequences or complication of pain, and effectiveness of current interventions for pain. 4. The staff and physician will monitor for adverse effects of pain medication. 5. If resident's pain is complex or not responding to standard interventions, the attending physician my consider additional consultative support. 6. If pain is stable and the underlying cause is resolved or it is unclear whether a source of pain remains, the physician will consider a trial reduction or elimination of analgesic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 1 of 22 residents, that the facility did not ensure that the resident's drug regimen was adequately monitored. Specifically, a resident was administered a medication used to treat hypertension when the resident's blood pressure was outside of parameters set by a physician's order. Resident Identifier: 24 Findings Include: Resident 24 was admitted [DATE] with diagnoses which included intertrochanteric fracture of left femur, fracture of the lower end of the left radius, essential (primary) hypertension, and hyperlipidemia. Resident 24's medical record was reviewed from 1/6/25 through 1/8/25. Resident 24's physician orders and Medication Administration Record (MAR) were reviewed from December 2024 through January 2025. Resident 24 had a physician's order that stated, Metoprolol Tartrate Oral Tablet 25 MG [milligrams] Give 0.5 tablet by mouth two times a day for HTN [hypertension] hold for SBP [systolic blood pressure] < [less than] 100 or apical pulse <60. This order was started on 12/28/24. Resident 24 had an additional physician's order that stated,BP [blood pressure]/Cardiac Med [medication]: Hold Medication if SBP<90 and/or DBP [diastolic blood pressure] <50 Pulse<55 two times a day for [sic] Notify MD [doctor of medicine]/APRN [Advanced Practice Registered Nurse] if held for 3 consecutive doses [sic] Document notification of MD/APRN. This order was started on 12/5/24. On 1/5/25 at 8:00 PM, Resident 24 was administered a 0.5 oral tablet of Metoprolol Tartrate 25 MG. Resident 24's systolic blood pressure was documented as a 96. Resident 24's diastolic blood pressure was documented as a 60. Resident 24's pulse was documented as a 76. On 1/8/25 at 9:17 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that a resident's blood pressure medication should be held if the resident's blood pressure was below the parameters set by the physician's order. On 1/8/25 at 10:14 AM, an interview was conducted with RN 3. RN 3 stated that if a resident had two conflicting orders for blood pressure medications, then the parameters specified by the medication order itself should be followed. On 1/8/25 at 11:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if there were two conflicting orders for blood pressure medications, then whichever order was placed most recently should be followed. The DON stated that on 1/5/25 resident 24 should not have received the 0.5 oral tablet of Metoprolol Tartrate 25 MG when his systolic blood pressure was below the parameters set in the physician's order for the medication. The DON also stated that the order placed on 12/5/24 should have been discontinued when the medication order was placed on 12/28/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that its antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed a course of antibiotic therapy for a urinary tract infection without a culture and sensitivity report to verify that the organism was susceptible to the antibiotics ordered. Resident identifier 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, urinary tract infection, type 2 diabetes mellitus, congestive heart failure, chronic kidney disease, benign prostatic hyperplasia, pain, and presence of urogenital implants. On 1/8/25, resident 7's medical records were reviewed. On 12/4/24, resident 7 had an order initiated for Bactrim Tablet 800-160 milligram (mg) (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth in the morning for urinary tract infection (UTI) for 5 days. Resident 7's December 2024 Medication Administration Record (MAR) documented that resident 7 received Bactrim from 12/4/24 through 12/8/24 for a total of 5 doses administered. On 12/24/24, resident 7 had an order initiated for Cefdinir Capsule 300 mg, give 1 capsule by mouth two times a day for UTI for 7 days. Resident 7's December 2024 MAR documented that resident 7 received Cefdinir from 12/24/24 through 12/27/24 for a total of 6 doses administered. It should be noted that resident 7 was discharged from the facility on 12/27/24 before the completion of the antibiotic. On 12/23/24, resident 7's urinalysis (UA) documented abnormal values for red blood cells (RBC) 31-40, white blood cells (WBC) 6-10, Bacteria 1+, urine clarity cloudy, and moderate amount of blood in the urine. No documentation could be found in resident 7's medical records for a urine culture and sensitivity report. The facility December 2024 Infection Control tracking and trending log was reviewed. On 12/3/24, the log documented that resident 7 was admitted to the facility with a UTI and the treatment ordered was Bactrim 1 tablet for 5 days. The log documented to continue per the hospitalist and no culture was obtained. On 12/24/24, the log documented that resident 7 had a UTI and Cefdinir 300 mg two times a day for 7 days was ordered. The log documented that a culture was not obtained due to Did not meet criteria for cx [culture]. On 1/08/25 at 2:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the laboratory completed the UA on 12/23/24 but did not test the specimen for a culture and sensitivity. The DON stated that they could not determine if the organism was susceptible to the antibiotic ordered without the culture and sensitivity report. The DON stated that resident 7's family member was insistent that he had a UTI and was symptomatic. The DON stated that she spoke with resident 7's provider and he ordered to continue the antibiotic treatment. The DON stated that it was unusual that the lab did not send the specimen for a culture, and she did not call the lab to verify and ask why they did not send the sample for a culture. The DON stated that it was reported to her by a nurse that the culture was not obtained because the laboratory stated it did not meet their criteria for a culture. The DON stated that she should have followed up with the lab on why the test was not performed. Review of the facility policy for Antibiotic Stewardship documented that all clinical infections treated with antibiotics would undergo review by the infection preventionist or designee to identify specific situation not consistent with appropriate use of antibiotics. The policy documented that therapy may require further review and possible changes if: i. organism is not susceptible to antibiotic chosen; ii. organism is susceptible to narrower spectrum antibiotic; iii. therapy was ordered for prolonged surgical prophylaxis; or iv. therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. The policy was dated 11/15/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 4 of 22 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary psychotropic drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use. Specifically, resident's psychotropic medications did not have a corresponding diagnosis or adequate indication for use. Resident identifier: 30, 83, 136 and 139. Findings included: 1. Resident 30 was admitted to the facility on [DATE] and passed away on 11/4/24 with diagnoses which included diverticulitis, need for assistance with personal care, muscle wasting, heart failure, chronic obstructive pulmonary disease and chronic respiratory failure. Resident 30's medical record was reviewed 1/6/25 through 1/8/25. A physician's note dated 11/3/24 revealed resident 30 had a history of diverticulosis, chest was clear, cardiac was regular, abdomen was benign and vital signs were stable. The assessment and plan revealed On going support care, medication management. Antibiotics until course is complete. She has shown overall improvement. Continue supportive care until stable for discharge. A nursing progress note 11/3/24 at 10:28 AM from Registered Nurse (RN) 1 revealed that resident was alert and oriented to person, place and time. Resident 30 had clear speech and was able to understand and understood when she was talked to. Resident 30 did not have shortness of breath, posterior middle lobe and left posterior upper lobe were diminished on auscultation. Resident 30's abdomen was flat, non-tender with bowel sounds present x 4. Resident 30's skin was clean, dry and intact. Resident 30 was able to move all extremities with no limited range of motion. Resident and responsible party were aware of diagnosis and plan of care. A Brief Interview of Mental Status (BIMS) was completed on 11/3/24 at 1:05 PM. Resident 30's BIMS was 15 which indicated cognitively intact. Resident 30's physician's orders revealed an order for dated 11/3/24 for Lorazepam Oral table 0.5 milligrams (mg) three times a day as needed for anxiety. The November 2024 Medication Administration Record (MAR) was reviewed and revealed the Lorazepam 0.5mg tablet was administered to resident 30 on 11/3/24 at 7:22 PM and on 11/4/24 at 1:51 AM. The next nursing progress note from RN 2 revealed on 11/4/24 at 4:40 AM, patient's vitals ceased this morning around 3:30am. daughter present at bedside. Pt [patient] will be released to mortuary. On 1/7/25 at 3:11 PM, a interview was conducted with RN 2. RN 2 stated she looked through resident 30's medical record and remembered resident 30's daughter was at the bedside. RN 2 stated she came to work and was told during the nurse to nurse report that resident 30 was actively dying. RN 2 stated she remembered resident 30's change was sudden. RN 2 stated resident 30 had stopped taking her medications and unresponsive when she came on for shift. RN 2 stated resident 30 was getting anti-anxiety medications. RN 2 stated resident 30's daughter was at bedside and she told the nurse that resident 30 did not want any interventions and wanted to die peacefully. RN 2 stated she provided her some Ativan (anti-anxiety medication) because she was anxious. RN 2 stated resident 40 woke up about 2:00 AM and was talking with her daughter. RN 2 stated she asked for her sleeping medication about an hour later and was administered the medication and passed away. RN 2 stated nurses should document if someone was actively passing away. RN 2 stated she was in the room often checking on resident 30 throughout the night. On 1/7/25 at 2:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated for resident 30 the nursing progress notes indicated resident 30 was doing well and there was no documentation of a change in condition. The DON stated according to physician's orders Lorazepam was ordered on 11/3/24 and there should have been documentation regarding why the anti-anxiety was ordered. 2. Resident 83 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of greater trochanter of right femur, need for assistance with personal care, diabetes mellitus, fibromyalgia, insomnia and heart failure. Resident 83's medical record was reviewed 1/6/25 through 1/8/25. Resident 83's physician's orders revealed the following: a. On 12/17/24 for Quetiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for depression. The order was discontinued on 12/18/24. b. On 12/18/24 for Quetiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Insomnia. A form with no titled revealed a typed form with Quetiapine written in with a diagnosis of insomnia hand written with a physicians signature dated 12/18/24. The typed form revealed Patient is currently prescribed Quetiapine for diagnosis of insomnia. Dose reduction contraindicated at this time. Recommend follow up with prescribing/primary care physician after discharge from short term rehab at [name of facility]. On 1/8/25 at 1:34 PM, an interview was conducted DON. The DON stated when a resident was admitted their diagnoses were provided from the hospital. The DON stated the admitting nurse connected the diagnosis with each medication. The DON stated an off label use for Quetiapine was insomnia so that would be an appropriate diagnosis for the anti-psychotic medication. 3. Resident 136 was admitted to the facility on [DATE] with diagnoses which included hypertension chronic kidney disease, peptic ulcer, low back pain, history of pulmonary embolism, fracture of left radius, thyrotoxicosis, and obstructive sleep apnea. On 1/6/25 through 1/8/25, resident 136's medical records were reviewed. On 1/4/25, resident 136's had an order initiated for Hydroxyzine Tablet 10 milligram (mg), give one tablet by mouth two times a day for anxiety. No documentation could be found in resident 136's medical records of a diagnosis of anxiety disorder or any specific condition as diagnosed and documented in the medical records that would indicate the use of a medication to treat anxiety. On 1/7/25 at 12:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 136 was alert and oriented times 3-4 to person, place, time and situation. RN 1 stated that resident 136 had some confusion about medications upon wakening this morning. RN 1 stated that resident 136 did not have any behaviors and was taking Hydroxyzine for anxiety. RN 1 stated that resident 136 did not have a diagnosis listed in their medical records for anxiety. RN 1 stated that she would review the hospital paperwork to see if the resident had a diagnosis of anxiety. RN 1 was observed reviewing resident 136's hospital history and physical and problem list and stated that she did not see a diagnosis for anxiety disorder. On 1/7/25 at 12:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident had medication for anxiety and depression she would expect to see a diagnosis to go with that medication order. The DON stated that they were contacting the provider for the Hydroxyzine order and indication for use. 4. Resident 139 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of the right patella, orthopedic aftercare, cerebral palsy, dorsalgia, scoliosis, pain in right knee, acute candidiasis, muscle wasting and atrophy, hypertension, congenital malformations of the spine, hearing loss, cardiac murmur, nonrheumatic mitral valve prolapse, and arthrodesis status. On 1/6/25 through 1/8/25, resident 139's medical records were reviewed. On 12/13/24, resident 139 had an order initiated for Duloxetine Capsule Delayed Release Sprinkle 60 mg, give one capsule by mouth two times a day for depression. On 12/14/24, resident 139 had an order initiated for Ambien Tablet 5 mg, give one tablet by mouth at bedtime for sleep. No documentation could be found in resident 139's medical records of a diagnosis of depression or insomnia or any specific condition as diagnosed and documented in the medical records that would indicate the use of a medication to treat depression and insomnia. On 1/7/25 at 1:41 PM, an interview was conducted with RN 1. RN 1 stated that resident 139's Ambien was ordered for sleep and the Duloxetine was ordered for depression. RN 1 stated that resident 139 did not have a diagnosis of depression or insomnia. RN 1 stated that she would expect to see a diagnosis for the medication prescribed but could not find one for the Ambien or Duloxetine. On 1/7/25 at 1:43 PM, an interview was conducted with the DON. The DON stated she would expect to see a diagnosis of depression and insomnia for resident 139's Duloxetine and Ambien orders. The DON stated that she could not find a corresponding diagnosis for the medications. The DON stated that resident 139 was on the medications at home. The DON stated that the hospital ordered to discontinue the Ambien and they initially had resident 139 on Melatonin. The DON stated that resident 139 requested to have the Ambien started again.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cellular phones and a bluetooth speaker were stored on a drying rack used to store clean dishes and utensils in the kitchen, foods were stored inappropriately in the kitchen freezer, and staff did not serve food in a sanitary manner. Findings Include: On 1/6/24 at 9:25 AM, an observation was made of the drying rack next to the dish machine in the kitchen. On one of the shelves there was a bluetooth speaker and two cellphones with charging cords stored on the drying rack. The drying racks also had clean dishes and cooking utensils stored on the racks. On 1/6/24 at 9:32 AM, an observation was made of the kitchen freezer. There was a box of frozen blueberries open to the air. The blueberries were stored inside a plastic bag inside the box. Both the bag and box were open to air. There was a box of coconut cream pies and a box of breadsticks stored on the floor of the freezer. On 1/8/25 at 11:30 AM, an observation was made of the facility servery used to plate meals served to residents of the facility. There were food splatters stuck to the drop ceiling tile directly above food preparation areas. On 1/8/25 at 12:08 PM, the Head Certified Nursing Assistant (CNA) was observed to stick her finger inside a resident's plate of pasta to brush some peas off of the pasta and to another side of the plate. The plate had been passed from the Dietary Aide to the Head CNA. The Head CNA was not wearing any gloves. The meal was served to a resident sitting in the facility dining room. On 1/8/25 at 12:43 PM, the Head CNA was observed grabbing an ice cream scoop that had been placed on top of the sink in the dirty side of the dishwashing area of the servery. The Head CNA rinsed the ice cream scoop with water, and then handed it to CNA 1. CNA 1 then used the scoop to scoop ice cream to serve to residents sitting in the dining area. On 1/8/25 at 1:01 PM, an observation was made of the Head CNA's wired earpiece falling out of her ear and into a plate of pasta. The Head CNA removed the earpiece, placed it back into her ear, and served the plate of pasta to a resident sitting in the dining room. On 1/8/25 at 1:28 PM, an interview was conducted with the Head CNA. The Head CNA stated that during food service, staff should not touch food with their bare hands and that they should only touch the outer rims of plates. The Head CNA stated that the ice cream scoop used to serve ice cream should be stored in a cup of water in between use during meal service. The Head CNA stated the kitchen staff should provide a clean scoop each time a CNA requested a scoop. On 1/8/25 at 2:08 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that staff should wear gloves whenever they touch food so that their fingers do not come into contact with the food. The DM stated that the plates used at the facility have a large rim to prevent staff from touching food with their fingers when serving the food to residents. The DM stated that cellphones should not be stored on the drying racks in the kitchen. The DM stated that a clean ice cream scoop should be used when serving ice cream to residents and that soiled ice cream scoops should be washed with soap and water before being used again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 22 sampled residents, that the facility did not 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, a licensed nurse was observed to touch medication with contaminated gloves, alcohol swabs were placed on unclean surfaces prior to use, and used lancets were not disposed of in the sharps container. Resident identifier 85. Findings included: Resident 85 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, encounter for orthopedic aftercare, muscle wasting and atrophy of the right and left shoulder, hypothyroidism, type 2 diabetes mellitus, hypomagnesemia, generalized anxiety disorder, insomnia, chronic pain, encephalopathy, and hypertension. On 1/6/25 through 1/8/25, resident 85's medical records were reviewed. Resident 85's medication orders included the following: a. Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth four times a day for pain. b. Aspirin 81 mg, give 1 tablet by mouth two times a day for deep vein thrombosis prophylaxis. c. Multivitamin with minerals, give 1 tablet by mouth one time a day for supplement. d. Oil of oregano capsule, give 2 capsules by mouth before meals and at bedtime. e. Calcium with Vitamin D3 tablet 600-10 mg-microgram, give one tablet by mouth two times a day for hypocalcemia prevention. On 1/8/25 at 8:52 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during the morning medication administration. LPN 1 dispensed medications for resident 85. LPN 1 donned gloves prior to preparation of the medication. LPN 1 was observed to touch the medication cart, opening multiple drawers, with her gloved hands. LPN 1 touched the computer mouse pad and key board with the same gloved hands. LPN 1 dispensed barrier cream from a communal bottle into a medication cup with the same gloved hands. LPN 1 then dispensed two Acetaminophen tablets, one Aspirin tablet, one Multivitamin with mineral tablet, two oil of oregano capsules, and one Calcium with vitamin D3 tablet by picking out each tablet from the medication bottles with the same gloved hands. It should be noted that during the preparation of resident 85's medication LPN 1 did not change her gloves and multiple surfaces were touched. LPN 1 then obtained supplies to check resident 85's blood sugar which included the glucose monitor with test strip, lancet, cotton swab, and alcohol pad. LPN 1 made 4 attempts at obtaining a blood sugar reading for resident 85. LPN 1 doffed and donned new disposable gloves after each failed blood sugar reading. After each attempt LPN 1 obtained a new alcohol prep pad, lancet, and monitor strip. It should be noted that LPN 1 did not perform hand hygiene after each blood sugar monitoring attempt and the changing of disposable gloves. LPN 1 was observed to open 3 alcohol prep pads and placed the pads directly onto resident 85's bedside table prior to use. It should be noted that the bedside table was not cleaned and disinfected prior to the alcohol prep pad being placed on the surface. LPN 1 also placed one opened alcohol prep pad directly onto the top of the monitor prior to use. LPN 1 was observed to dispose of all 4 used fingerstick lancets into a regular trash can, either inside the resident room or in a garbage can directly outside of the resident doorway in the hall. On 1/8/25 at 9:12 AM, an interview was conducted with LPN 1. LPN 1 stated that the finger stick lancet had a cover over the sharp tip and could be disposed of in the regular trash can. LPN 1 then stated that the used lancet should have been disposed of into the sharps container. LPN 1 stated that the alcohol swab should have been opened and used before it was placed on the bedside table. LPN 1 stated that this practice would have prevented any cross contamination of the unused alcohol pad. LPN 1 stated that when dispensing medication she typically touched the medication pills with gloved fingers and believed this was acceptable because her hands were gloved. LPN 1 confirmed that during the medication dispensing she touched multiple surfaces on the medication cart including the computer keyboard and mouse pad without changing her gloves. On 1/8/25 at 9:19 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that it was acceptable practice for staff to touch resident medication with gloved hands as long as other surfaces were not touched. The DON stated staff should be popping medication directly into the medication cup from the blister packs so they were not touching pills. The DON stated that staff should use any alcohol swabs upon opening the package. The DON stated that all used lancets should be disposed on in a sharps container. Review of the facility policy on Handwashing/Hand Hygiene documented that the facility considered hand hygiene the primary means to prevent the spread of infection. The policy further documented that hand hygiene with alcohol-based hand rub containing at least 62% alcohol or soap and water should be used for the following situations: a. Before and after direct contact with residents; b. Before preparing or handling medications; c. Before performing any non-surgical invasive procedures; d. After contact with a resident's intact skin; e. After contact with blood or bodily fluids; f. After contact with objects in the immediate vicinity of the resident. The policy documented that hand hygiene was the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. The policy documented that hand hygiene should be performed before applying non-sterile gloves and upon removal of those gloves. The policy was last revised in August 2019 and reviewed in March 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 of 22 sample residents, that the facility did not ensure that each resident's medical care was supervised by a physician. Specifically, one resident had a corded heating pad and ice machine for her back that were not ordered by the physician, and one resident had an ice machine that was not ordered. Resident identifiers: 1 and 281. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included low back pain, chronic bronchitis, muscle wasting, osteoporosis, tremor, glaucoma, and heart disease. On 10/5/21 at 2:03 PM, resident 1 stated that her back had recently popped and had hurt since. Resident 1 stated that her back had broken vertebrae. Resident 1 was observed to have a polar ice machine running on the right side of her bed, and a plugged heating pad was observed on the right side of resident 1's head, lying on the mattress. Resident 1 stated that she utilized heat and cold therapy to help control pain. On 10/6/21, resident 1's medical record review was completed. Resident 1's physician orders were reviewed in the electronic medical record and in resident 1's paper chart. No orders for heat or cold therapy were revealed. Resident 1's care plan was reviewed. Resident 1's care plan did not include heat or cold therapy. Resident 1's progress notes were reviewed. Nursing notes revealed: a. On 8/29/21 at 1:34 PM, .utilizing ice to relieve pain . b. On 9/24/21 at 4:05 PM, . Ice compress in place PRN (as needed) to help with pain c. On 9/25/21 at 11:17, .Ice compress in place . the ice helps a lot. Resident 1's care plan was reviewed. Resident 1 did not have a care plan for heat and/or cold therapy. There was no documentation that resident 1 was educated about safe heat and cold therapy. Resident 1's assessments were reviewed. Resident 1 was not assessed for safe use of an electric heating pad or ice therapy. On 10/6/21 at 11:11 AM, a physical therapy assistant (PTA) 1 was interviewed. PTA 1 stated that therapy provided moist heat pads, but did not provide electric heating pads to the residents. PTA 1 stated that therapy had not performed an assessment for Resident 1's safe use of a heating pad. PTA 1 stated that when heat and cold were prescribed, therapy discussed the safe use of the devices and timing. PTA 1 stated that Certified Nursing Assistants (CNAs) would be responsible to obtain ice for the electric ice machines, and would assist the residents with positioning if needed, and skin assessments after use. On 10/6/21 at 11:14 AM, CNA 6 was interviewed. CNA 6 stated that CNAs did not chart the use of heating pads or ice machines, but CNAs assisted residents to place the therapy and remove the device after 20 minutes. CNA 6 stated that nurses should acquire heat packs for residents who used heat therapy. On 10/6/21 at 11:30 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that resident 1 utilized the polar ice machine on her lower back to help control pain. RN 2 stated that she did not know when resident 1 utilized the heating pad. On 10/6/21 at 11:49 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 1 did not have an assessment to safely use a heating pad. The DON stated that resident 1 did not inform staff that she had a heating pad. The DON confirmed that there were no physician orders for heat or cold therapy, but that orders were required for residents to utilize heat or ice therapy. 2. Resident 281 was admitted to the facility on [DATE] with diagnoses which included a displaced fracture of the left femur, diabetes mellitus type 2, heart disease, hypertension, coronary artery graft, and edema. On 10/5/21 at 11:59 AM, resident 281 was observed resting in their room with a polar ice machine at the bedside. On 10/6/21 at 12:27 PM, resident 281 stated she had used the polar ice machine several times since having been admitted to the facility. Resident 281 reported the therapy staff may set the machine up, but the CNAs usually took it off. On 10/6/21, a review of resident 281's medical chart was completed. No physician orders were noted for use of ice therapy or a polar ice machine. On 10/06/21 12:45 PM, RN 3 reported a resident who was utilizing ice therapy would have a telephone order placed in their chart. RN 3 reported resident 281 did not have a physician order for ice therapy. RN 3 reported sometimes therapy staff delivered the polar ice machine to the resident and did not inform the nursing staff. RN 3 stated if this happened then a telephone order for ice therapy would not get placed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, 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, a visitor was observed to enter an isolation room without Personal Protective Equipment (PPE) of a gown or gloves, a staff member was observed to walk out of an isolation room and down a resident hallway without having taken off PPE upon exiting the isolation room, staff members were observed to cross contaminate resident meals during delivery, and a kitchen staff member was observed to transport a meal from the facility main kitchen to a smaller service area without covering the plated items. Resident identifier: 277 Findings include: 1. On 10/5/21 at 12:49 PM, resident 277 was observed to have a visitor enter their room without wearing the PPE required for an isolation room. [Note: Per facility signage outside of resident 277's door, those who enter the room were to wear PPE that included a gown, gloves, a face shield and a face mask.] Resident 277 was admitted to the facility on [DATE] with medical diagnoses that included, but were not limited to, encounter for orthopedic aftercare, arthrodesis, nausea, muscle wasting and atrophy of the right shoulder, left shoulder, and left thigh, unsteadiness on feet, abnormalities of gait and mobility, anxiety disorder, major depressive disorder, mononeuropathy, hypertension, gastro-esophageal reflux disease, constipation, spinal stenosis, low back pain, neuralgia and neuritis, urinary tract infection and hypoxemia. On 10/6/21 a review of resident 277's medical chart was completed. The following was noted: a. Resident 277 had an physician order in place for, Droplet/Contact precautions x 14 days every shift for 14 Days- Start Date 09/27/2021- End Date 10/11/2021. b. Resident 277 had a care plan in place which read, Resident non vaccinated upon admit precautions X 14 [days] as indicated. Interventions in place included, Droplet and contact precautions X 14 [days] as indicated,, Personal protective equipment per current CDC [The Centers for Disease Control and Prevention] and local Health Department recommendations, and, Resident will remain in room up to 14 days . pending PCR [polymerase chain reaction test] results and / or vaccination status. On 10/5/21 at 12:50 PM, Certified Nursing Assistant (CNA) 1 reported when a visitor entered a resident room who is on isolation for 14 days after admission, the visitor must wear a face mask, a face shield, gown and gloves. The visitor must put on the PPE before entering the room and should remove the gown and gloves at the doorway and dispose of these items in the garbage bin near the resident's door. On 10/5/21 at 12:52 PM, CNA 2 reported a resident who is on isolation for their first 14 days after admission can have a visitor in the room. The visitor must wear a face mask, a face shield, gloves and a gown when entering the resident's room. CNA 2 reported resident 277 was on isolation for their first 14 days in the facility because they were newly admitted and the resident was not fully vaccinated. CNA 2 stated that if the visitor was not told to wear PPE, it's probably ok for him not to wear it. On 10/5/21 at 1:30 PM, an interview was conducted with CNA 2. CNA 2 stated that the resident in room [ROOM NUMBER] was on contact precautions due to not having had a COVID-19 vaccination. CNA 2 stated that visitors should have been informed about the PPE requirements. 2. On 10/5/21 at 12:59 PM, an observation was made a hairdresser entering the room of resident 227. The hairdresser donned PPE and entered the room to talk to the resident. At 1:02 PM, the hairdresser was observed walking out of the room and to the nurses' station at the far end of the hallway still wearing her PPE. The hairdresser asked the nurse about the proper disposal of the PPE. The nurse stated that the PPE was to be thrown away inside the resident's room, but the hairdresser could throw it away at the nurses' station. The hairdresser was observed doffing the PPE and placing it in the garbage on the nurses' medication cart. 3. On 10/5/21 several observations were made during a lunch meal service. Observations of cross contamination were made through CNA staff not performing hand hygiene between resident rooms, and a meal being delivered and touched by one resident and then delivered to a different resident down the hall. On 10/5/21 at 12:13 PM, CNA 3 was observed to approach a resident in the dining room to assist with cutting the resident's food. CNA 3 was observed to adjust her face mask and then cut the resident's food without sanitizing her hands prior to assisting the resident. Then, without sanitizing her hands, CNA 3 continued to assist with placing plastic wrap over other resident meals for delivery. On 10/5/21 at 12:35 PM, CNA 4 delivered a resident lunch tray. While in the resident's room, CNA 4 assisted the resident in re-positioning within their bed. CNA 4 then exited this resident's room, and without sanitizing her hands, CNA 4 gathered the next resident lunch tray for delivery. On 10/5/21 at 12:47 PM, CNA 3 was observed to deliver a lunch tray to the resident in room [ROOM NUMBER]. Once the tray had been delivered, and the resident and visitor had touched the beverage, CNA 3 determined she had delivered the wrong tray to the resident in 3131. CNA 3 gathered the meal and beverage from room [ROOM NUMBER] and placed it back on the meal delivery cart. CNA 1, then walked this tray and beverage down the hall and delivered the meal and beverage to the resident in room [ROOM NUMBER]. On 10/5/21 at 12:27 PM, CNA 2 was observed taking a lunch tray to room [ROOM NUMBER]. CNA 2 set up the tray and then proceeded to pass a meal tray to a resident in room [ROOM NUMBER] without hand sanitizing. On 10/5/21 at 12:44 PM, CNA 2 was interviewed. CNA 2 stated that she did not use hand sanitizer because she didn't touch the resident. On 10/5/21 at 12:45 PM, CNA 1 was interviewed. CNA 1 stated that CNAs were taught to sanitize between each resident's room when passing hall trays to avoid cross-contamination. 4. On 10/5/21, during lunch service, several observations were made of a kitchen staff member walking from the facility's main kitchen to a smaller service area without covering resident food. [Note: In order to walk from the main kitchen to the smaller service area, the kitchen staff member would have to leave the meal preparation area.] On 10/5/21 at 12:10 PM, Kitchen Server (KS) 1 was observed to walk to the main kitchen and returned with a plated meal of mechanical soft tacos, rice and vegetables. The plate of food was observed to not be covered, and this plate was then delivered to a resident having lunch in the dining room. On 10/5/21 at 12:27 PM, KS 1 was observed to walk to the main kitchen and return with sauce in a bowl that was not covered. On 10/05/21 at 12:34 PM, Kitchen Server 1 and CNA 5 reported when a meal is special order or if it is a modified texture, Kitchen server 1 was walking to the main kitchen, gathering these meals, and then walking them down the hallway to the smaller service area. On 10/06/21 at 12:45 PM, the Food Service Director was interviewed. The Food Service Director reported the kitchen staff should cover all food items when they leave the main kitchen and are delivered to the smaller service area.