**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician; and notify when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, a resident expressed feelings of suicidal ideation and the physician was not notified. Resident identifier 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. Review of resident 39's physician orders revealed the following: a. Seroquel Oral Tablet 25 milligram (mg) (Quetiapine Fumarate), give 12.5 mg by mouth every morning and at bedtime for Anxiety/Delusions. The order was initiated and discontinued on 9/10/23. b. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth at bedtime for Anxiety/Delusions. The order was initiated on 9/7/23 and discontinued on 9/10/23. c. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth two times a day for Anxiety/Agitation. The order was initiated on 9/5/23 and was discontinued on 9/7/23. d. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for Agitation for 1 Day. The order was initiated on 9/5/23 and discontinued on 9/6/23. e. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for agitation for 1 Day. The order was initiated on 9/3/23 and discontinued on 9/4/23. f. Escitalopram Oxalate Oral Tablet 20 mg (Escitalopram Oxalate), give 20 mg by mouth one time a day for anxiety/agitation. The order was initiated on 9/2/23 and discontinued on 9/10/23. Review of resident 39's progress notes revealed the following: a. On 9/10/2023 at 12:55 PM, the nursing progress noted documented, Res [resident] became increasingly agitated/paranoid to the point of wandering around the halls and attempting exit. Staff assisted res around hallways and prevented exit. Res was seen kicking the doors and demanding staff walk in front of her to 'avoid any funny business'. Attempted to give Norco for pain, res refused. [Family member] notified, will be coming in to sit with patient. Notified [Nurse Practitioner] of behaviors - received orders to change seroquel 12.5mg back to BID [two times a day]. b. On 9/10/2023 at 6:08 PM, the progress note documented, Pt's [patient's] daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin (administration), pt did calm down but still not cooperative and refused to take any medications. It should be noted that no documentation could be found to show that the medical provider was notified of the incident with the knife. 11/14/23 at 2:36 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 39's family was really involved with her care. LPN 2 stated that resident 39's family was in the building (9/10/23) from 11:00 AM to 4:30 PM. LPN 2 stated that resident 39 was a difficult patient and had a lot of behaviors that included agitation, wandering, and paranoid thoughts. LPN 2 stated that resident 39 seemed like she had a long standing mental health issue and was very paranoid. LPN 2 stated that resident 39's daughter had informed her that resident 39 had said I wish I were dead, and then proceeded to grab a butter knife from her meal tray. The daughter reported that resident 39 then went after her husband with the knife and then resident 39 placed the knife to her neck. LPN 2 stated that this incident had occurred a day or two prior to resident 39's elopement on 9/10/23. LPN 2 stated that she made sure resident 39's bedroom door was always open; she was located next to the nurse's station; and they made sure resident 39 did not have sharp objects in her room. LPN 2 stated that she informed the charge nurse of resident 39's suicidal ideation, and she thought the charge nurse would notify the physician. LPN 2 stated that documentation of the physician notification should be in a progress note. On 11/15/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that this incident occurred while she was on leave. The DON stated any suicidal ideation or attempt should be reported immediately to the provider and the whole interdisciplinary team would be involved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the the allegation was made to the administrator, State Survey Agency (SSA), and Adult Protective Services. Specifically, a resident eloped from the facility and the State Survey Agency was not notified. Resident identifier 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. On 9/10/2023 at 6:08 PM, the resident 39's progress note documented, Pt's [patient's] daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin (administration), pt did calm down but still not cooperative and refused to take any medications. During dinner while staff were passing room trays, heard door alarm and noted pt was not in her room. Unable to find her in the parking lot. Charge Nurse aware and assisting in looking for pt and notified Administrator. While checking cars, noted pt to be walking in the road at the end of the block. A Samaritan stopped their truck and pt got into their vehicle when they noticed me running towards them. Pt became very agitated. I got into the truck and they gave us both a ride back to the main entrance of the facility. Charge Nurse and Admin notified EMS [Emergency Medical Services] and Law Enforcement as well as pt's daughter [name omitted] and [name of Nurse Practitioner omitted] of incident and that pt would be transferred to [local area emergency room (ER)] for a psych [psychiatric] eval. Pt pleasant and cooperative at this time, but does become more irritable and agitated the more people show up around her. Able to assist pt into Ambulance safety and without incident. Transported to ER and informed she will not be coming back to the facility. It should be noted that no documentation could be found to show that the SSA was notified of resident 39's elopement on 9/10/23. On 11/15/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that this incident occurred while she was on leave. The DON stated that an elopement was normally something that should be reported to the SSA. The DON stated that they thought that resident 39's elopement did not need to be reported because the resident was not anticipated to return to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that the resident received care, consistent with professional standards of practice, to prevent the development of pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident developed a new pressure ulcer after admission to the facility and interventions were not implemented specific to the prevention of its development. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of left humerus, syncope and collapse, chronic kidney disease, dementia, peripheral vascular disease, prediabetes, history of venous thrombosis, and long term use of anticoagulants. On 11/14/23 at 9:43 AM, an observation was made of resident 23. Resident 23 right lower extremity was positioned in a podus boot with a stocking over the top of the foot. Resident 23 stated that she could feel a sore spot on the back of her ankle and that she wore the boot all the time. On 11/15/23, resident 23's medical records were reviewed. On 7/3/23, resident 23's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 5/15, which would indicate a severe cognitive impairment. The assessment documented that resident 23 was an extensive 2-person assist for bed mobility, transfer, ambulation in room/corridor, locomotion on/off unit, dressing, toilet use, and personal hygiene. The assessment documented that resident 23 used a walker and wheelchair as a mobility device. Review of resident 23's physician orders revealed the following: a. Wound Care: Right heel: apply skin prep every day shift for wound care. The order was initiated on 8/5/23. b. Wound Care: Left heel: Apply skin prep every day shift for wound care. The order was initiated on 8/12/23. c. Wound Care: Right heel Deep Tissue Injury (DTI): Clean with Normal Saline (NS) or wound cleanser, apply Silvakollagen, cover with dry dressing every day shift for wound care. The order was initiated on 8/12/23. d. WOUND CARE: Right Heel - Remove old dressing, cleanse with NS, place plain aquacel or alginate over wound bed, place foam dressing with skin prep every other day and as needed (PRN). The order was initiated on 9/27/23. e. WOUND CARE: Right Heel - Cleanse with Puracyn, apply skin prep to peri wound, apply Endoform on wound bed, cover with a dry dressing every day shift every 3 day(s) for wound care. Only Replace Endoform if it comes off. The order was initiated on 10/18/23. f. Keep feet elevated with bootie on right heel to offload every shift for wound care. The order was initiated on 9/27/23. g. Apply heel protectors when in bed or recliner two times a day for Wound care. The order was initiated on 8/5/23. h. Remind aides to place toe spacers on during day off at night two times a day for toes. The order was initiated on 7/6/23. Review of resident 23's progress notes revealed the following: a. On 6/26/2023 at 5:03 PM, the note documented, Assessed resident skin no sign of pressure sore on coccyx, buttock, heels. No excoriation in peri area. Did note dry cracked heels, and toe nail fungus. b. On 8/3/2023 at 10:04 PM, the note documented, Pt [patient] complained of pain on R [right] heel to CNA [Certified Nurse Assistant] and called nurse in. Nurse observed what appears to be a Deep Tissue injury on R heel. Notified wound care nurse. received orders to apply skin prep and float heels until she could take a look Friday 8/4. Approximately 1x [by]1 unblanchable purple area. c. On 8/5/2023 at 6:41 PM, the Skin/Wound note documented , Right heel DTI [Deep Tissue Injury] -Measuring 2.5 x 2.5 x 0 -Place heel protectors on -Tx [treatment] per wound care orders d. On 8/5/2023 at 6:42 PM, the note documented to apply skin prep to the right heel DTI, and apply heel protectors when in bed or recliner for protection. e. On 8/10/2023 at 9:37 AM, the Skin/Wound note documented, Note Text: R heel DTI -Measuring 3.5 x 4 x 0.1 -Minimal drainage -Cleaned et [and] tx per wound care orders Stage I pressure sore -Measuring 0.7 x 0.5 x 0.1 -Tx per wound care orders f. On 8/10/2023 at 11:30 AM, the note documented, Called Residents daughter [name omitted] to notify her about DTI on right heel and interventions (heel protectors, slippers when not in therapy, skin prep, bigger shoes) in place, daughter will get bigger shoes to prevent causing pain and pressure. g. On 8/18/2023 at 3:24 PM, the Skin/Wound note documented, Note Text: R heel DTI -Measuring 2.5 x 2.5 x 0.1 -Minimal drainage -Cleaned et tx per wound care orders L [left] heel Stage 1 -Measuring 0.8 x 0.4 x 0 -Tx per wound care orders h. On 8/25/2023 at 9:13 AM, the Skin/Wound note documented, Note Text: Right heel DTI -Measuring 2 x 2.2 x 0.1 -Minimal drainage -10% pink wound bed 90% eschar -Cleaned et tx per wound care orders left heel Stage 1 pressure sore -Measuring 0.4 x 0.5 x 0 -Tx per wound care orders i. On 9/1/2023 12:10 PM, the Skin/Wound note documented, Right heel unstageable DTI -Measuring 2.5 x 2.5 x 0.1 -Minimal drainage -Pale wound bed -30% Pink 70% stationary slough -Cleaned et tx per wound care order j. On 9/8/2023 at 11:47 PM, the Skin/Wound note documented, R heel unstageable DTI -Measuring 2.5 x 2.5 x 0.1 -90% slough, 10% granulation -Minimal drainage -Cleaned et tx per wound care orders k. On 9/14/2023 at 1:01 PM, the Skin/Wound note documented, Right unstageable pressure ulcer -Measuring 1.5 x 2.5 x 0.1 -55% slough, 45% Granulation -Moderate drainage -Cleaned et tx per wound care orders l. On 9/19/2023 at 10:19 AM, the note documented, [Physician name omitted] looked at Wound culture and Ordered Ciprofloxacin 500 mg [milligrams] BID [two times a day] x [times] 10 days for Infection in Left heel pressure ulcer. He also ordered to send her to Wound clinic at [local area hospital]. m. On 9/19/2023 at 12:56 PM, the Skin/Wound Note documented, Got DTI d/t [due to] sitting in white chair where family wants her to sit to be able to see outside. They do not want her sitting in recliner d/t 'it makes her nauseas (sic)'. n. On 9/22/2023 at 11:51 AM, the Skin/Wound Note documented, R heel unstageable pressure ulcer -Measuring 2.3 x 2 x 0.1 -Moderate drainage -55% slough, 45% Granulation -Macerated peri wound -Cleaned et tx per wound care orders o. On 9/27/2023 at 11:11 AM, the Skin/Wound Note documented, Patient returned from apt [appointment] with [physician name omitted] DPM [Doctors of Podiatric Medicine] in good spirits. Progress note as follows, Patient's wound needs to be debrided and we will do a better job of keeping pressure off the back to heal so we have dispensed a Podus boot and will start with a foam dressing with alginate dressing. Patient to return to clinic in 1 week or sooner if there is any problems. p. On 9/27/2023 at 11:24 AM, the Skin/Wound Note documented, Wound care orders from [physician name omitted] DPM as follows, 'R Heel, Cleanse with Puracyn. Use plain aquacel or alginate as the primary dressing, use bordered foam as the secondary dressing. May use skin protectant PRN [as needed] to help with dressing adherence. This order is to be carried out Every other Day, more PRN for soiling/dislodgment. Offload with mulipodus boot on right foot as often as patient will tolerate, with special emphasis on when patient is in bed or sitting in a chair when her feet are resting against anything such as a footrest. Continue to protect left heel. Keep wound dry when showering and bathing. [Name of facility omitted] If patient misses/doesn't have a wound care appointment SNF [skilled nursing facility] to change 4 times that week. Continue orders until the end of certification period or until new orders are received. q. On 10/5/2023 at 11:16 AM, the Skin/Wound Note documented, R heel unstageable pressure ulcer -Measuring 2.2 x 1.5 x 0.1 -Minimal drainage -50% slough, 50% granulation tissue -Cleaned et tx per wound care orders r. On 10/18/2023 at 12:46 PM, the Skin/Wound Note documented, resident came back from wound clinic with new orders: -Right heel: Cleanse w/Puracyn, Apply Skin Prep peri wound where adhesive border of dressing touches the skin. Use Endoform as primary dressing, Leave in place during the week. Replace if it comes off. Extra sent with patient. Use Foam Border dressing as secondary dressing. May use skin protectant PRN to help with dressing adherence. This order to be carried out Q3D [every 3 days] and PRN when soiled or wet. Offload with Multipodus boot on right foot as patient tolerates. Keep wound dry when showering. s. On 10/24/2023 at 1:24 PM, the Skin/Wound Note documented, R heel stage 4 pressure ulcer -Measuring 2.5 x 2 x 0.2 -100% granulation -Moderate drainage -Macerated peri wound t. On 11/14/2023 at 3:29 PM, the Skin/Wound Note documented, R heel stage 4 pressure ulcer -Measuring 2 x 1.4 x 0.1 -Moderate drainage -90% granulation 10% slough -cleaned et tx per wound care order Resident 23's care plan documented the following: a. A focus area for The resident has increased risk for pressure ulcer or potential for pressure ulcer development related to decreased movement and has stage 4 pressure ulcer to right heel. The care plan was initiated on 6/26/2023. It should be noted that the care plan was initiated on the date of resident 23's admission, but the nursing skin assessment on 6/26/23 did not identify any skin alterations. Furthermore, the DTI was not identified on the right heel until 8/3/23. Interventions identified included: Administer Multivitamin, Vitamin C, Zinc for wound healing as ordered per physician (initiated on 8/14/23); Administer treatments as ordered and monitor for effectiveness (initiated on 6/26/23); Follow facility policies/protocols for the prevention/treatment of skin breakdown (initiated on 6/26/23); Follow wound care orders to Left heel (initiated on 8/8/23); Follow wound care orders to Right heel (initiated on 8/16/2/3); If The resident refuses treatment, confer with the resident, Interdisciplinary Team (IDT) and family to determine why and try alternative methods to gain compliance. Document alternative methods (initiated on 6/26/23); Inform the resident/family/caregivers of any new area of skin breakdown (initiated on 6/26/23); Monitor nutritional status, serve diet as ordered and monitor intake and record (initiated on 6/26/23); and Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort (initiated on 6/26/23). b. A focus area for The resident has infection of the Right heel pressure ulcer. The care plan was initiated on 9/19/23. Interventions identified on the care plan were to administer antibiotic per physician orders; maintain universal precautions when providing resident care; monitor temperature/pulse; monitor/document/report to physician as needed for signs and symptoms (s/sx.) of a urinary tract infection (UTI): frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes; and monitor/document/report to physician any s/sx of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. On 11/15/23 at 11:23 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 23 just went to wound clinic and on those days that she goes to wound clinic they did not perform wound care. LPN 2 stated that resident 23's current order for wound care were for every three days. On 11/16/23 at 8:58 AM, an observation was made of resident 23 seated in the dining room eating breakfast. Resident 23 had the right lower extremity podus boot applied. An immediate observation was made of resident 23's room. The resident did not have an air mattress applied to the bed. The resident's preferred seat was a chair situated at the foot of the bed and was not a recliner. On 11/16/23 at 9:04 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 23 had a sore on her heel. CNA 1 stated that after the development of the pressure ulcer they floated resident 23's heel and the boot was supposed to keep pressure off the heel. CNA 1 stated that when resident 23 was sitting in the chair they placed a pillow below her ankles to keep it from touching the floor. CNA 1 stated that resident 23 preferred the chair and not a recliner and it was difficult to float the foot in the chair. CNA 1 stated that resident 23 was on a regular mattress. On 11/16/23 at 9:16 AM, an interview was conducted with LPN 3. LPN 3 stated that the protocol for pressure ulcer prevention was to rotate or turn the resident every 2 hours, apply barrier cream, and monitor the skin condition at least daily or every shift. LPN 3 stated that any signs or symptoms of skin breakdown were to be reported to the charge nurse or wound care nurse and they would create a care plan. On 11/16/23 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility protocol for prevention of skin breakdown was to identify any high risk residents and to reposition the resident frequently. The DON stated that the wound nurse evaluated all new admits and if the resident was identified as high risk they would put an air mattress or a gel cushion in the chair. The DON stated that resident 23 had a gel cushion. The DON stated that resident 23 did not have an order for an air mattress or the gel cushion. The DON stated that resident 23's heel boots were ordered after the pressure ulcer was identified. The DON stated that they identified an intervention to float resident 23's heels when the DTI was identified on 8/3/23. The DON stated that resident 23 preferred to sit in the chair and they encouraged the recliner to elevate her feet. The DON stated that they implemented wound clinic after the development of the wound infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards was was possible and that the resident received adequate supervision to prevent accidents. Specifically, a resident who was identified as exit seeking did not have adequate supervision to prevent the resident from eloping. Resident identifier: 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. Review of resident 39's physician orders revealed the following: a. Seroquel Oral Tablet 25 milligram (mg) (Quetiapine Fumarate), give 12.5 mg by mouth every morning and at bedtime for Anxiety/Delusions. The order was initiated and discontinued on 9/10/23. b. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth at bedtime for Anxiety/Delusions. The order was initiated on 9/7/23 and discontinued on 9/10/23. c. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth two times a day for Anxiety/Agitation. The order was initiated on 9/5/23 and was discontinued on 9/7/23. d. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for Agitation for 1 Day. The order was initiated on 9/5/23 and discontinued on 9/6/23. e. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for agitation for 1 Day. The order was initiated on 9/3/23 and discontinued on 9/4/23. f. Escitalopram Oxalate Oral Tablet 20 mg (Escitalopram Oxalate), give 20 mg by mouth one time a day for anxiety, agitation. The order was initiated on 9/2/23 and discontinued on 9/10/23. Review of resident 39's progress notes revealed the following: a. On 9/1/2023 at 2:49 PM, the progress note documented that resident 39 was admitted after a ground level fall, had extensive dementia, and utilized a cane for mobility. b. On 9/3/2023 at 8:57 PM, the note documented, Pt [patient] has refused to take any meds PO [by mouth] today. Nurse earlier tried to admin [administer] them whole which she refused, and then tried them crushed and pt then decided that it was poison and that all her food was poisoned and refused to eat. Unable to reason with her. Pt's daughter was in earlier today and they brought in a hamburger and tried to get her to eat. Daughter reports that pt has a long history of dementia and has advanced to a higher state of paranoia. Daughter told me that pt was convinced that the TV was spying on her, that her son was installing cameras to watch her. Daughter reports that she has been cleaning out her home and that she has found several dirty, broken and useless items that have had to be thrown away. Daughter also reported an incident of physical aggression towards her husband where she tried to choke him. Daughter reports that she has had several fractures and repairs done. Pt has began wandering in halls and looking for her daughter. Going into other patients rooms looking for her family, and then began accusing family of trying to trick her. Unable to redirect her or reason with her. Requires constant 1:1 to prevent her form going outside or confronting other patients. Notified [Administrator's name omitted] and [Nurse Practitioner's (NP) name omitted]. Received order for 1mg Ativan PO. [Administrator] talked with daughter [name omitted] and was able to get her to come in and stay with pt 1:1. Daughter was able to get pt to take medications including Ativan which was effective. Pt's left arm is visibly red, swollen, and warm. Was started on Keflex for post op infection yesterday. Unable to keep it immobilized. She has removed splint and wrap several times and will not leave the sling in place. But has been better to leave the splint and wrap on today. c. On 9/5/2023 at 4:08 PM, the note documented, [Nurse Practitioner name omitted] ordered Seroquel 12.5mg PO BID [two times daily] and One time dose of Ativan 1mg PO Now d/t [due to] resident trying to run away and Paranoid thinking people want to poison her. d. On 9/6/2023 at 2:41 PM, the note documented, CNA's [Certified Nurse Assistants] charted the resident was wondering and having repetitive movements. e. On 9/10/2023 at 12:55 PM, the note documented, Res [resident] became increasingly agitated/paranoid to the point of wandering around the halls and attempting exit. Staff assisted res around hallways and prevented exit. Res was seen kicking the doors and demanding staff walk in front of her to 'avoid any funny business'. Attempted to give Norco for pain, res refused. Daughter [name omitted] notified, will be coming in to sit with patient. Notified [name omitted] NP of behaviors - received orders to change seroquel 12.5mg back to BID. f. On 9/10/2023 at 6:08 PM, the note documented, Pt's daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin [administration], pt did calm down but still not cooperative and refused to take any medications. During dinner while staff were passing room trays, heard door alarm and noted pt was not in her room. Unable to find her in the parking lot. Charge Nurse aware and assisting in looking for pt and notified Administrator. While checking cars, noted pt to be walking in the road at the end of the block. A Samaritan stopped their truck and pt got into their vehicle when they noticed me running towards them. Pt became very agitated. I got into the truck and they gave us both a ride back to the main entrance of the facility. Charge Nurse and Admin notified EMS [Emergency Medical Services] and Law Enforcement as well as pt's daughter [name omitted] and [NP name omitted] of incident and that pt would be transferred to [local area hospital] ER [emergency room] for a psych [psychological] eval [evaluation]. Pt pleasant and cooperative at this time, but does become more irritable and agitated the more people show up around her. Able to assist pt into Ambulance safety and without incident. Transported to ER and informed she will not be coming back to the facility. It should be noted that no documentation could be found of monitoring for exit seeking behaviors, nor interventions to prevent elopement. 11/14/23 at 2:36 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 39's family was really involved with her care, and if resident 39 could get out she would. LPN 2 stated that resident 39 had a fractured elbow, and the goal was to get her recovered enough to return home. LPN 2 stated that resident 39 was confused and would wander. LPN 2 stated that resident 39 needed to be a 1:1 with a staff and her family would also stay with her. LPN 2 stated on the day of the elopement resident 39's family was in the building from 11:00 AM to 4:30 PM. LPN 2 stated that when they were passing dinner trays they heard an alarm. LPN 2 stated that they went to the front door to look for resident 39 and they found her walking in the middle of the street down by the round about. LPN 2 stated that a bystander was talking to resident 39. LPN 2 stated that this incident occurred towards the end of her day shift. LPN 2 stated that in the past if resident 39 was up and wandering they would call the resident's daughter and she would come in and sit with her. LPN 2 stated that resident 39 would wander up and down the hallway. LPN 2 stated that resident 39 was a difficult patient and had a lot of behaviors that included agitation, wandering, and paranoid thoughts. LPN 2 stated that resident 39 seemed like she had a long standing mental health issue and was very paranoid. LPN 2 stated that she suspected that resident 39 had bipolar disorder. LPN 2 stated that resident 39's daughter had said that the resident thought her son was putting cameras up to watch her. LPN 2 stated that resident 39 also thought that they were poisoning her food and she would not take her medication. LPN 2 stated that resident 39's daughter had informed her that resident 39 had said I wish I were dead, and then proceeded to grab a butter knife from her meal tray. The daughter reported that resident 39 then went after her husband with the knife and then resident 39 placed the knife to her neck. LPN 2 stated that this incident had occurred a day or two prior to resident 39's elopement on 9/10/23. LPN 2 stated that they were working on transferring resident 39 to another facility, because she did not qualify for their locked unit. LPN 2 stated that she made sure resident 39's bedroom door was always open; she was located next to the nurse's station; and they made sure resident 39 did not have sharp objects in her room. LPN 2 stated that the day of the elopement they ended up calling dispatch and the resident was transferred to the hospital. On 11/15/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON) and the Wound Nurse (WN). The DON stated that this incident occurred while she was on leave. The DON stated that at the time of the elopement resident 39 was not on 1:1 with a staff member. The WN stated that they tried to keep resident 39 at the nurse's station to monitor her and they would try to keep her busy with activities. The WN stated that since they were not doing 1:1 with a staff the family tried to be present as much as possible. The WN stated that when they realized she needed more assistance they tried to place her in memory care unit. The WN stated that interventions to keep resident 39 safe were to have her room located close to the nurse's station; kept her busy with activities; and they would take her to get a soda or an ice cream. The WN stated that the interventions were passed on in report. The WN stated that they administered Lorazepam to help with resident 39's anxiety. The WN stated that resident 39 would frequently say, i want to go home, where's my family. The WN stated that they tried to have staff watch her more when the family wasn't present. The WN stated that every time resident 39 was close to walking out they would call the family and they would come sit with her. The WN stated that they did not have a care plan for wandering or at risk for elopement as the resident was still in the 14 day window to develop them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's medication was not administered per the physician ordered parameters. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included acute posthemorrhagic anemia, dissection of thoracoabdominal aorta, atrial fibrillation, heart failure, depression, diabetes and fibromyalgia. Resident 26's medical record was reviewed 11/13/23 through 11/16/23. A form from a home health company dated 10/27/23 revealed an order for ergocalciferol 1.25 milligrams (mg) (500 intl (international) units) oral capsule (cap). Administration of 1 cap every week. An order note in the progress notes dated 10/27/23 revealed This order is outside of the recommended dose or frequency. Ergocalciferol Oral Capsule 1.25 MG (50000 UT) (Ergocalciferol) give 1 capsule by mouth at bedtime for supplement. The daily dose of 1 capsule exceeds the usual dose of 0.1428 to 0.1429 capsule. The frequency of daily exceeds the usual frequency of every 7 days. A physician's order dated 10/27/23 revealed Ergocalciferol Oral Capsule 1.25 MG (50000 UT) Give 1 capsule by mouth at bed time for supplement. The order was discontinued on 11/7/23. The Medication Administration Record (MAR) October 2023 and November 2023 revealed Ergocalciferol was administered daily from 10/27/23 until 11/6/23. A physician's order dated 11/10/23 revealed Ergocalciferol Oral Capsule 1.25 MG (50000 UT) . Give 1 capsule by mouth one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday], Sun [Sunday] for supplement. The MAR for November 2023 revealed Ergocalciferol was administered 11/12/23, 11/13/23 and 11/15/23. An order note in the progress notes revealed on 11/7/23, This order is outside of the recommended dose or frequency. Ergocalciferol Oral Capsule 1.25 MG (50000 UT) (Ergocalciferol) Give 1 capsule by mouth one time a day every Mon, Wed, Fri Sun for Supplement. The daily dose of 0.5714 capsule exceeds the usual dose of 0.1428 to 0.1429 capsule. The frequency of 4 times per week exceeds the usual frequency of every 7 days. Resident 25's pharmacy reviews were completed for October 2023 and November 2023. There were no irregularities documented by the pharmacist. On 11/15/23 at 3:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident was admitted the medication list was faxed to the pharmacy. The DON stated the nurse entered the medication into the electronic medical record. The DON stated resident 26 was getting 50,000 units of Ergocalciferol daily and it should have been weekly. The DON stated the medication was transcribed wrong and was administered daily to resident 25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that residents who have 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. Specifically, a resident was prescribed an antipsychotic medication for insomnia. Resident identifier: 31. Findings included: Resident 31 was admitted on [DATE] with diagnoses which included laceration of muscles and tendons of the right lower extremity, tear of meniscus, coronary artery disease, chondromalacia, gout, dysarthria and anarthria, polyneuropathy, tremor, polyosteoarthritis, thrombocytopenia, hypothyroidism, and presence of bypass graft. On 11/15/23, resident 31's medical records were reviewed. Resident 31's physician orders revealed an order for Seroquel Oral Tablet 50 milligrams (mg) (Quetiapine Fumarate), give 1 tablet by mouth at bedtime for agitation. The order was initiated on 7/12/23. The Nursing 2022 Drug Handbook documented Seroquel's therapeutic drug class was an antipsychotic and was indicated to treat Schizophrenia, Bipolar I Disorder, Bipolar Depression, and Major Depressive Disorder. [NAME]. Nursing 2022 Drug Handbook. Philadelphia PA: Wolter Kluwer. 2022. p.1250-1255. On 11/15/23 at 1:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that when resident 31 was admitted he had a lot of situational depression, and initially he was not participating in therapy. LPN 2 stated that resident 31 was prescribed Seroquel to help him sleep and not to treat any psychosis. LPN 2 stated that the resident did not have any diagnoses of depression, schizophrenia, or bipolar disorder. On 11/15/23 at 1:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Seroquel was initially ordered in the hospital for insomnia. The DON stated that they realized during the psychotropic meeting that it was not prescribed for any mental health disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, for 2 of 23 sampled residents, a urinalysis was not done as requested by the provider and a resident did not have ordered labs completed. Resident identifiers: 31 and 32. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. On 9/16/23 at 5:21 PM, a nurse note stated, Pt [patient] continues on PO [by mouth] ABTx [antibiotics] for UTI [urinary tract infection], however, urine remains significantly bloody. Received orders from [name removed] to do a f/u [follow up] UA [urinalysis] 72 hrs after last dose of antibiotics. Pt and family aware. Physician's orders revealed the following laboratory orders: a. A physician order dated 9/16/23 read as follows, UA with C&S [culture and sensitivity] 72 hours after PO ABTx complete. 9/20/2023. One time only for Hematuria for 1 Day. [Note: this diagnostic order was ordered to be done on 9/20/23.] There were no laboratory results provided by the facility or located in resident 32's medical record. On 11/16/23 at 9:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there was not UA results for 9/20 and stated they were unable to find the order in the resident's medication administration record/ treatment administration record. The DON stated the order was put incorrectly and because of that the nurse was not flagged to obtain a UA that day. The DON stated if an order was put under diagnostic, it went no where in the resident's chart to alert staff. On 11/16/23 at 11:37 AM, an interview was conducted with the Medical Doctor (MD). The MD stated they ordered the follow up UA on 9/20/23 to make sure there was not any evidence of an ongoing infection from his foley catheter/irritation, nephrolithiasis, or irritation from stone due to resident 32 having the bloody urine. The MD stated the expectation was to obtain the UA if they had ordered it. 2. Resident 31 was admitted on [DATE] with diagnoses which included laceration of muscles and tendons of the right lower extremity, tear of meniscus, coronary artery disease, chondromalacia, gout, dysarthria and anarthria, polyneuropathy, tremor, polyosteoarthritis, thrombocytopenia, hypothyroidism, and presence of bypass graft. On 11/15/23, resident 31's medical records were reviewed. On 7/19/23, an order for a Complete Blood Count (CBC) was initiated for resident 31. No documentation could be found of the CBC laboratory results in resident 31's medical records. On 11/15/23 at 12:50 PM, an interview was conducted with the DON. The DON stated that the order for the CBC was not obtained. The DON stated that the day nurse was not able to get a sample and she thought she passed it on to the night shift to complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 23 sample residents, that the facility did not ensure that resident's laboratory reports were filed in the clinical record. Specifically, a resident's urine culture results were not in the resident's medical record. Resident identifier 32. Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. A physician order dated 9/8/23 for a urinalysis and culture and sensitivity due to signs and symptoms of a UTI was reviewed. The laboratory results for the above listed physician's order were not located in resident 32's electronic medical record. Resident 32 progress notes were reviewed and documented the following: a. On 9/25/23 at 4:01 PM, a nurse note stated, Also, resident reports [name removed], PA [physician assistant], took a UA @ [at] [name removed] Urology, which should have results 'soon'. b. On 9/27/23 at 2:23 PM, a nurse note stated, Requested UA results from Lab - suspected gram negative bacilli identified, susceptibility still pending. Will continue to monitor for culture results. c. On 9/28/23 at 3:44 PM, a nurse note stated, .Called [clinic name removed] Urology and left this information for PA, [name removed]. Receptionist stated he is looking into UA Cx [culture] status. This nurse left the Nature desk phone number with her and asked for [name removed] to call with any f/u [follow up] orders. Will continue to monitor. d. On 9/28/23 at 4:09 PM, a nurse note stated, [name removed], [clinic name removed] Urology, called and stated he received the messages left today re: [resident 32]. He stated, since resident's catheter is currently patent and resident's has a hx [history] with ABX [antibiotic] resistant bladder infections, he would rather wait for thecx [sic] results to grow out. He agreed to call with orders when CX has grown out. It should be noted that the urine culture results collected on 9/25/23 at the urologist office were not located in resident 32's electronic medical record. On 11/16/23 at 11:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the charge nurses were the one's responsible for keeping an eye out for lab results. LPN 1 stated normally lab results were upload into the resident's chart once they get them. LPN 1 was unable to locate resident 32's urine culture report for 9/8/23 and 9/25/23. LPN 1 stated they had an issue with the local hospital sending lab results back in a timely manner in the past. On 11/16/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated lab results were uploaded into the residents charts once they had been noted by the medical doctor (MD). The DON stated the charge nurse printed out the lab results and then gave it to the MD to review. The DON stated once the MD had reviewed and noted the results, they were given to medical records to upload them. The DON stated they were changing the process up so results were upload into the resident charts in a more timely manner. The DON stated they wanted to have results in the resident charts within 3 days of receiving the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 23 sampled residents, that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that was complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's physician's orders did not match the medication administered. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included acute posthemorrhagic anemia, dissection of thoracoabdominal aorta, atrial fibrillation, heart failure, depression, diabetes mellitus and fibromyalgia. Resident 26's medical record was reviewed 11/13/23 through 11/16/23. Resident 26's admission physician's orders dated 10/27/23 revealed Metoprolol Succinate Extended Release (ER) 50 milligrams (mg) oral tablet daily (QD). A physician's order in resident 26's electronic medical record dated 10/27/23 revealed Metoprolol Tartrate 50 MG by mouth QD. Resident 26's October and November 2023 Medication Administration Record (MAR) revealed that Metoprolol Tartrate 50 MG was administered daily. On 11/15/23 at 1:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated she was not sure if Metoprolol Succinate and Metoprolol Tartrate were the same. LPN 2 stated she would have to ask the pharmacist. LPN 2 was observed to look at a phone and then stated after looking at the difference, the Tartrate was not extended release and needed to be administered twice daily. LPN 2 stated the Succinate was extended release and needed to be administered once daily. LPN 2 stated those were two different medications and she would need to contact the physician to obtain a clarification order for resident 26. On 11/15/23 at 2:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated admission orders were obtained from the hospital sent to the pharmacy. On 11/15/23 at 3:10 PM, a follow-up interview was conducted with the DON. The DON stated that resident 26 was receiving the Succinate and not the Tartrate. The DON stated that the Succinate was an extended release should be administered once daily. The DON stated the Tartrate was short acting and needed to be administered more often. The DON stated resident 26 was receiving the appropriate medication but it was documented incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not establish an infection prevention and control program that included, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 23 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with the incorrect antibiotic that was not listed on the susceptibility laboratory report. Resident Identifier: 32 Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. Resident 32's progress notes were reviewed and documented the following: a. On 9/9/23 at 10:13 AM, a nurse note stated, [name removed] NP [nurse practitioner] seen [sic] Pt [patient] today for symptoms of a UTI [urinary tract infection]. Ordered Keflex 500mg [milligrams] PO [by mouth] TID [three times a day] x7 days . b. On 9/16/23 at 5:21 PM, a nurse note stated, Pt continues on PO ABTx [antibiotics] for UTI, however, urine remains significantly bloody. Received orders from [name removed] to do a f/u [follow up] UA [urinalysis] 72 hrs [hours] after last dose of antibiotics. Pt and family aware. On 9/11/23, a finalized urine culture result, documented resident 32 had a UTI due to having grown out an organism. It should be noted that the prescribed antibiotic [Keflex] was not included on the susceptibility list. On 11/16/23 at 9:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated nurses went off resident symptoms to determine if they had a UTI. The DON stated the symptoms included frequency, change in urine odor, change in urine status, flank pain and a change in the resident's activities of daily living or cognition. The DON stated once a resident had these symptoms, the physician was notified, and a UA was collected. The DON stated a urine culture was always ordered in conjunction with the UA. The DON stated sometime the lab did not run a urine culture if the UA looked clean. The DON stated a UA resulted within 4-6 hours and a urine culture took 2-3 days for results. The DON stated if a resident had a long history of UTIs, most times the physician waited to start them on antibiotics until the urine culture had been finalized so the resident was not started on an antibiotic, they were resistant too. The DON stated sometimes the physician started a resident on antibiotics before the urine cultures were finalized but made adjustments to the antibiotic once the urine culture results were available. On 11/16/23 at 11:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a resident experienced UTI symptoms, they notified the doctor who then ordered a UA based on the symptoms a resident was experiencing. LPN 1 stated a urine culture was always ordered with a UA. LPN 1 stated the doctor sometimes prescribed broad spectrum antibiotics based on the UA results and would then adjust the antibiotics according to the urine culture results. On 11/16/23 at 11:37 AM, an interview was conducted with the Medical Doctor (MD). The MD stated once the urine culture results were finalized, they were printed and given to the provider to see if any adjustments needed to be made to the prescribed antibiotic. The MD stated the susceptibility report gave a representative drug in the category. The MD stated as long as the antibiotic prescribed was included in the same drug class that the organism was susceptible to, it was effective in treating the UTI. The MD stated the antibiotic prescribed to resident 32 on 9/9/23 needed to be changed. The MD stated the drug class equivalent to Keflex, indicated the organism which grew in resident 32's urine was resistant to the antibiotic prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 32 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. On 11/14/23 at 10:36 AM, an interview was conducted with resident 32. Resident 32 stated they were sick a while ago and had to go to the hospital because of it. Resident 32 stated that was why he was still on the IV [intravenous] antibiotics. Resident 32's medical record was reviewed on 11/14/23. Resident 32's progress notes revealed the following: a. On 10/26/23 at 1:04 PM, a nurse note stated, Resident's spouse came to the desk and reported resident was shaking despite turning up the thermostat and receiving blanket coverage x 2 . b. On 10/26/23 at 3:32 PM, a nurse note stated, Received information from the CNAS [certified nursing assistants] that resident had thrown up. Upon assessment, resident was breathing 28 times/min. Resident stated he felt tight in his abd [abdomen]. [Name removed], NP [nurse practitioner], assessed. Stated resident should continue on with NC [nasal cannula] for the time being. This nurse called [name of local hospital] lab and enquired about UA [urinalysis] status. Reportedly, it had been run and results needed to be recorded in their computer system. This nurse asked for the results to be put in their computer ASAP [as soon as possible]. Receptionist verbalized understanding and stated she would hurry the results along. Spoke with resident's daughter and informed her about the situation. Forwarded the message about the labs to [name removed], NP. Will continue to monitor. c. On 10/26/23 at 4:08 PM, a nurse note stated, Resident's UA was resulted and reviewed by [name removed], NP. Resident has a substantial urinary infection. [name removed] gave the following order: Sent to [local hospital] ER [emergency room] for Eval [evaluation] and tx [treatment]. Dx [Diagnosis]: vomiting, chilling, tachypnea, and hypoxia . On 11/3/23, a hospital history and physical documented the facility did not give the hospital any additional information other than the facility was concerned resident 32 had a deep infection. The hospitalist documented resident 32 had had multiple UTI's in the past month and had a history of Proteus grown with his urine cultures which made it hard to treat due to a drug resistance. It should be noted that no documentation could be found that indicated what information was provided to the receiving institution or provider. On 11/16/23 at 9:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was sent to the hospital, they normally tried to call the ER to give them report. The DON stated the documents sent with the resident included the face sheet, medication list, POLST [physician form for life sustaining treatment] form and sometimes the recent vitals' signs. The DON stated they were not aware of nurses having to document a transfer assessment. The DON stated when a resident transferred to the hospital the nurses documented a progress note about it. On 11/16/23 at 11:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a resident was transferred to the hospital, the nurses sent over the resident face sheet, the MAR [medication administration record] to show what medication they had been taking, an order summary, and a POLST form. The LPN 1 stated they also included a progress note in the resident's chart which included why the resident was transferred, where they were transferred to, and the mode of transportation used to get to the facility. Based on interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the information provided to the receiving provided included: contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; Advanced Directive information; all special instructions or precautions for ongoing care; all other necessary information, including a copy of the resident's discharge summary; and any other documentation to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found of the information that was provided to the receiving provider. Resident identifier 32, 39 and 93. Findings included: 1. Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. On 9/10/2023 at 6:08 PM, the resident 39's progress note documented, Pt's [patient's] daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin (administration), pt did calm down but still not cooperative and refused to take any medications. During dinner while staff were passing room trays, heard door alarm and noted pt was not in her room. Unable to find her in the parking lot. Charge Nurse aware and assisting in looking for pt and notified Administrator. While checking cars, noted pt to be walking in the road at the end of the block. A Samaritan stopped their truck and pt got into their vehicle when they noticed me running towards them. Pt became very agitated. I got into the truck and they gave us both a ride back to the main entrance of the facility. Charge Nurse and Admin notified EMS [Emergency Medical Services] and Law Enforcement as well as pt's daughter [name omitted] and [name of Nurse Practitioner omitted] of incident and that pt would be transferred to [local area emergency room (ER)] for a psych [psychiatric] eval. Pt pleasant and cooperative at this time, but does become more irritable and agitated the more people show up around her. Able to assist pt into Ambulance safety and without incident. Transported to ER and informed she will not be coming back to the facility. It should be noted that no documentation could be found of a discharge summary or any information that was provided to the receiving provider. On 11/14/23 at 2:16 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the day of resident 39's elopement she was transported to the hospital. LPN 2 stated that resident 39 should have been sent to the hospital with a face sheet, medication list, Physician Orders for Life Sustaining Treatment (POLST) form, most recent weight and vital signs, and then the nurse should call and give report to the emergency room (ER). On 11/15/23 at 2:21 PM, a follow-up interview was conducted with LPN 2. LPN 2 stated that she thought the charge nurse (CN) 1 handled the transfer paperwork. LPN 2 stated that normally she would complete the discharge summary in the assessments and it would detail everything going to the receiving provider. On 11/16/23 at 9:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they send a POLST, face sheet, Medication Administration Record to the receiving provider and then call report to the ER. The DON stated that staff document the transfer in a progress note and it should include what paperwork was sent to the receiving provider. 2. Resident 93 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, atrial fibrillation, chronic kidney disease, congestive heart failure, hyperlipidemia, restless leg syndrome, hyperaldosteronism, obstructive sleep apnea, chronic pain, thrombocytopenia, and polyneuropathy. On 11/16/23, resident 93's medical records were reviewed. On 5/31/23, resident 93's Quarterly MDS Assessment documented a BIMS score of 14/15, which would indicate that the resident was cognitively intact. The assessment documented that resident 93 was an extensive 2-person assist for bed mobility and toilet use; and extensive 1-person assist for transfers, locomotion on/off unit, dressing and personal hygiene. Review of the facility initial investigation, form 358, documented, On 6/21/23 at 4:41 PM, the facility reported that on 6/21/23 at 9:30 AM the resident [93] was being transferred to a chair in her room, at the residents request, by 2 therapy staff members. The legs of the resident buckled and the resident fell causing a laceration in her lower leg that required sutures. The therapy staff alerted the nursing staff, the ADON [Assistant Director of Nursing]/wound nurse and the hospice nurse of the situation. The hospice nurse alerted the family. The NP [Nurse Practitioner] arrived at the facility to assess the resident prior to the resident being sent to the ER. No other injuries reported. No other agencies were notified. Review of resident 93's progress notes revealed no documentation of the residents transfer to the ER on [DATE]. On 6/21/23 at 9:30 AM, resident 93's Initial Post Fall Clinical Review documented, sent to ER for sutures and rule out fractures. On 6/21/23, the ER note documented, Outside historians: We did get some history from EMS who was at the scene and brought her in today. They provided some of the HPI [History of Present Illness]. The ER note further documented, We reviewed recent and relevant documentation to help in the management of this patient. These included: I did review an admission hospitalist note from a month ago where she came in in respiratory distress On 11/16/23 at 12:53 PM, an interview was conducted with the DON. The DON stated that the information from the transfer to the hospital was contained in the initial post fall assessment. It should be noted that the post fall assessment did not document the paperwork that was provided to the receiving provider.

**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, food in the refrigerator was not dated and labeled. In addition, there were soiled areas in the kitchen. Findings included: 1. On 11/13/23 at 11:07 AM, an initial tour of the kitchen was conducted. The following observations were made: a. The floor in the bistro area under the cappuccino machine had black build up and debris in the corners. b. The doors and handles on the refrigerator in the bistro area were soiled. c. There was a container labeled Cream Cheese Frosting with no open date or expiration date in the walk in refrigerator. d. There was thawed Whipped Topping in the walk in refrigerator with no date when it was pulled from the freezer. The label revealed to use thawed Whipped Topping within 2 weeks. e. There was black substance in the corners of the kitchen, around table legs and under shelves throughout the kitchen. There was black substance under the shelving that had pans and dishware on it. f. The vents on the ceiling and the ceiling above the food preparation area had dust on and around them. There was dust on the pan hanging rack above the meal preparation area. g. Under the ice machine there was white, brown and black substance on the floor. h. There was food splatter on the ceiling. i. There was debris and dust on the back of the Alternate Dining Preparation refrigerator. j. Inside the Alternate Dining Preparation refrigerator the following observations were made: i. Macaroni salad dated 10/29. ii. A plastic bag labeled BLT (bacon, lettuce and tomato) Bacon dated 11/7. ii. Another plastic bag with bacon that had no date or label. iii. A yellow pepper cut in half with no date and had mold on it. iv. Containers with lettuce, tuna, hard boiled eggs, tomatoes, cheese, onions, turkey, ham and cheese were not labeled or dated. k. The shelf above the trayline line foods was soiled underneath. 2. On 11/16/23 at 12:36 PM, a follow-up observation of the the kitchen was conducted. The following was observed: a. Under the boxes of soda for the soda machine there was black substance on the floor. b. Vents on the ceiling above trayline and above the food preparation area had dust on them. c. Cream cheese frosting in the [NAME] refrigerator did not have an open date. d. There was black substance in the corners of the kitchen, around table legs and under shelves throughout the kitchen. There was black substance under the shelving that had pans and dishware on it. e. The vents on the ceiling and the ceiling above the food preparation area had dust on and around them. There was dust on the pan hanging rack above the meal preparation area. f. Under the ice machine there was white, brown and black substance on the floor. g. There was food splatter on the ceiling. h. There was debris and dust on the back of the Alternate Dining Preparation refrigerator. i. The shelf above the trayline line foods was soiled underneath. j. The ice machine had a filter that had dust and debris above where the ice machine was opened to get ice out. An interview was immediately conducted with the Dietary Manager (DM). The DM stated the ice machine was cleaned every 3 months but the filter should be cleaned nightly. The DM stated the kitchen staff performed a Double Scrub every 3 months after the kitchen was closed. The DM stated the last double scrub was June of 2023 and everything was cleaned including the ceiling. The DM stated the trayline was cleaned every day after each meal. The DM stated the shelf above the trayline food had not been cleaned and needed to be cleaned. The DM stated alternative dining area was also called the Sandwich/line fridge. The DM stated that all the items were for sandwiches and alternative meals. The DM stated all items should be marked with the date they were put into the container and the last date to use. The DM stated after each shift the cooks restocked and refilled the items in the refrigerator. The DM stated the dust on the ceiling above food preparation table, the pots and pans rack, and vents on the ceiling needed to be dusted. The DM stated the cream cheese frosting was from 11/15/23. [It should be noted the item was observed on 11/13/23.]

**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 1 of 23 sample residents was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, a resident was not seen timely by a physician or physician surrigate. Resident identifier: 12, Findings included: Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of Alzheimer's disease, dementia, osteoarthritis, irritable bowel syndrome, hypertension, major depressive disorder, gastro-esophageal reflux disease, hyperlipidemia, and obstructive and reflux uropathy. On 1/13/22 resident 12's medical records were reviewed. Review of resident 12's physician progress notes revealed physician visits occurred on 1/20/21, 3/19/21, 3/20/21, 3/30/21, 4/23/21, 6/1/21, 8/2/21, 10/4/21, and 1/6/22. It should be noted that 93 days lapsed from the visit on 10/4/21 to the visit on 1/6/22. On 1/13/22 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the goal was to have the provider see the resident at least one time a week. The DON stated that they currently had a lot of Primary Care Providers (PCP) who did not want to do this. The DON stated that residents who had other PCP that were not the facility medical director were being seen on an as needed basis. The DON stated that resident 12's PCP did not like to see the resident unless it was necessary. The DON stated that she was aware that resident 12 had not been seen every 60 days per the regulatory guidelines. The DON stated that the PCP would not come to the facility at all and the residents had to be sent out for an appointment or a telehealth appointment was scheduled. The DON stated that this was why she was trying to transition to having the medical director oversee all of the resident care. The DON stated that the medical director was trying to do this in a diplomatic way to not upset the other providers. The DON stated that medical records did an audit on admit and discharge for physician visits and that the transportation staff also tracked this. The DON stated she was not sure how resident 12 fell through the cracks and missed physician visits every 60 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that medical records were complete, accurately documented, readily accessible and systematically organized for 3 of 23 sample residents. Specifically, hospice notes and physician visit notes had not been placed in the residents ' medical records. Resident identifiers: 17, 27 and 34. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis, hereditary motor and sensory neuropathy, anxiety disorder, and atrial fibrillation. Resident 17's medical record was reviewed on 1/10/22. Review of resident 17 ' s medical record revealed that no physician visits notes had been placed in the resident ' s record since 7/16/21. On 1/13/22, the Director of Nursing (DON) provided physician visit notes indicating that resident 17 had been seen by the facility physician on 7/29/21, 8/5/21/21, 8/13/21, 8/20/21, 8/25/21, 9/8/21, 9/17/21, 10/2/21, 10/8/21, 10/14/21, 10/22/21, 10/26/21, 11/11/21, 11/19/21, 12/7/21, 12/8/21, and 12/27/21. On 1/13/22, an interview was conducted with the DON. The DON confirmed that the above listed physician visit notes had not been placed in resident 17 ' s medical record prior to 1/13/22. The DON stated that she had identified that there was an issue with physician visits being placed in residents ' medical records in a timely manner, but had not yet been able to correct the issue. 2. Resident 34 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 4, anemia, hypothyroidism, major depressive disorder, generalized anxiety disorder, and low back pain. Resident 34 ' s medical record was reviewed on 1/10/22. Review of resident 34 ' s medical record revealed that no physician visits notes had been placed in the resident ' s record since 12/2/20. In addition, the resident was on hospice during that time, but had been discharged from hospice services on 11/26/21. No hospice notes regarding the coordination of resident 34 ' s care were located in the medical record. On 1/12/22, the DON provided physician visit notes indicating that resident 34 had been seen by the facility physician on 1/6/21, 1/27/21, 2/24/21, 3/31/21, 4/28/21, 5/26/21, 6/30/21, 8/3/21, 10/1/21, 12/1/21, 12/2/21, 12/16/21, 12/28/21, and 1/11/22. On 1/12/22 at 2:45 PM, an interview was conducted with the DON. The DON confirmed that the above listed physician visit notes had not been placed in resident 34 ' s medical record prior to 1/12/22. The DON also confirmed that no hospice notes were in resident 34 ' s medical record prior to 1/12/22, and that she had asked the hospice company to fax over their records on 1/12/22. 3. Resident 27 was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s disease, dementia, hypertension, atrial fibrillation, major depressive disorder, anxiety and bladder dysfunction. Resident 27 ' s medical record was reviewed on 1/20/22. Review of resident 27 ' s medical record revealed that no physician visits had been placed in the resident ' s record since 4/23/21. In addition, the resident had been placed on hospice services as of 12/23/20. No hospice notes regarding the coordination of resident 27 ' s care were located in the medical record. On 1/12/22, the DON provided physician visit notes indicating that resident 27 had been seen by the facility physician on 2/20/21, 4/20/21, 6/20/21, 8/16/21, 10/18/21, and 12/10/21. On 1/12/22, at 2:45 PM, an interview was conducted with the DON. The DON confirmed that the above listed physician visit notes had not been placed in resident 27 ' s medical record prior to 1/12/22. The DON also confirmed that no hospice notes were in resident 27 ' s medical record prior to 1/12/22, and that she had asked the hospice company to fax over their records on 1/12/22.

Based on interview and record review it was determined, for 5 out of 5 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed two times per week. Staff identifiers: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5. Findings included: On 1/10/22 at 9:55 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility receptionist kept the staff logs for testing and tracked who tested. The ADM stated that there were no scheduled days of the week for testing, and that staff could test any day. The ADM stated that it was difficult to ensure that all unvaccinated staff were testing two times per week according to the county community transmission rate. The ADM stated that staff were reluctant to come into the facility for testing if they were not already scheduled to work. On 1/11/22 the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website listed the Level of Community Transmission for the last 7 day Metrics as High for the county. The CDC COVID Data Tracker Levels of Community Transmission Time Lapse documented the county Community Transmission as High every day from 12/7/21 through 12/23/21 and again on 12/27/21 through 1/11/22. On 1/11/22 at approximately 4:15 PM, a follow-up interview was conducted with the ADM. The ADM stated that she tracked the county positivity rate and documented the information in her journal. Review of the facility ADM tracking journal documented the county positivity rate as follows: a. On 10/18/2021 - County positivity rate 8.9%, 2 weeks below 10% will go to testing 1x/week. b. On 11/2/2021 - County positivity rate is 11.6% c. On 11/9/2021- County positivity rate is 11.5% d. On 11/16/2021- County positivity rate is 10.3% e. On 11/23/2021- County positivity rate is 11.6% f. On 11/30/2021- County positivity rate is 12.2% g. On 12/7/2021- County positivity rate is 12.2% h. On 12/14/2021- County positivity rate is 10.9% i. On 12/21/2021- County positivity rate is 9.2% j. On 12/28/2021- County positivity rate is 8.6% k. On 1/3/22 - County positivity rate over 10% l. On 1/10/22 - County positivity rate 27.81% On 1/11/21 the facility surveillance testing log for November 22, 2021 through January 9, 2021 were reviewed. Staff testing logs were reviewed for the following unvaccinated staff members: a. Staff 1 surveillance testing was completed on 1/1/22. Test type and results were not documented on the testing log. No testing was conducted for Week 11/22/21 to 11/29/21, Week 11/29/21 to 12/6/21, Week 12/6/21 to 12/13/21, Week 12/13/21 to 12/19/21, Week 12/20/21 to 12/26/21, and Week 1/3/22 to 1/9/22. Staff 1 time cards documented days worked in December 2021 as 12/9/21, 12/11/21, 12/12/21, 12/13/21, and 12/14/21. b. Staff 2 surveillance testing was completed on 11/24/21, 12/1/21, 12/8/21, 12/9/21, 12/17/21, 12/30/21, and 1/3/22. Test type and results were not documented on the testing log. Staff 2 was missing the second surveillance test for Week 11/22/21 to 11/29/21, Week 11/29/21 to 12/6/21, Week 12/13/21 to 12/19/21, Week of 12/26/21 to 1/2/22, and Week 1/3/22 to 1/9/22. No testing was conducted for the Week of 12/20/21 to 12/26/21. It should be noted that staff 2 tested on two consecutive dates, 12/8/21 and 12/9/21. Staff 2 time cards documented days worked in December 2021 as 12/9/21, 12/17/21, 12/30/21, and 12/31/21. c. Staff 3 surveillance testing was completed on 11/24/21, 12/14/21, 12/19/21, 12/29/21, and 1/1/22. Test type and results were not documented on the testing log. Staff 3 was missing the second surveillance test for Week 11/22/21 to 11/29/21. No testing was conducted for the Week 11/29/21 to 12/6/21, Week 12/6/21 to 12/13/21, Week of 12/20/21 to 12/26/21, and Week 1/3/22 to 1/9/22. Staff 3 time cards documented days worked in December 2021 as 12/11/21, 12/13/21, 12/14/21, 12/16/21, 12/18/21, 12/19/21, 12/20/21, 12/28/21, and 12/29/21. d. Staff 4 surveillance testing was completed on 12/1/21, 12/10/21, 12/17/21, 12/29/21, 1/1/22, 1/3/22, and 1/8/22. Test type and results were not documented on the testing log. Staff 4 was missing the second surveillance test for Week 11/29/21 to 12/6/21, Week 12/6/21 to 12/13/21, and Week 12/13/21 to 12/19/21. No testing was conducted for the Week 11/22/21 to 11/29/21, and Week 12/20/21 to 12/26/21. Staff 4 time cards documented days worked in December 2021 as 12/1/21, 12/2/21, 12/3/21, 12/6/21, 12/8/21, 12/10/21, 12/11/21, 12/12/21, 12/13/21, 12/15/21, 12/17/21, 12/18/21, 12/20/21, 12/26/21, 12/27/21, 12/29/21, and 12/31/21. e. Staff 5 surveillance testing was completed on 11/30/21, 12/3/21, 12/8/21, 12/16/21, 12/20/21, 1/4/22, and 1/6/22. Test type and results were not documented on the testing log. Staff 5 was missing the second surveillance test for Week 12/6/21 to 12/13/21, Week 12/13/21 to 12/19/21, and Week 12/20/21 to 12/26/21. No testing was conducted for Week 11/22/21 to 11/29/21 and Week of 12/26/21 to 1/2/22. Staff 5 time cards documented days worked in December 2021 as 12/1/21, 12/2/21, 12/3/21, 12/6/21, 12/7/21, 12/8/21, 12/9/21, 12/10/21, 12/11/21, 12/12/21, 12/14/21, 12/15/21, 12/16/21, 12/17/21, 12/20/21, 12/21/21, 12/22/21, 12/23/21, 12/24/21, 12/27/21, and 12/28/21. On 1/12/22 at 10:19 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the ADM monitored the county positivity rate and emailed the numbers to her. The DON stated that the county positivity rate had been above 10%, and the ADM notified how often they should be testing the unvaccinated staff based on the county positivity rate. The DON stated that unvaccinated staff had been testing two times per week forever. The DON stated that the receptionist at the front desk tracked the unvaccinated staff testing and sent a reminder to staff to come in and get tested. The DON confirmed that the unvaccinated staff were not coming to the facility to test if it was their scheduled day off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 23 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, including COVID-19. Specifically, an unvaccinated newly admitted resident on Transmission Based Precautions (TBP) did not isolate in their room for 14 days after admission and was allowed to exit the droplet isolation room to attend therapy services in the facility gym. Staff were observed not donning the appropriate Personal Protective Equipment (PPE) prior to entering rooms on droplet precautions, and did not sanitize their protective eyewear upon exit of droplet precaution rooms. Staff were observed to enter and exit a droplet precaution room without doffing the PPE prior to entering another resident room, and housekeeping equipment was taken into the droplet precaution room and then into another resident room for use. Staff were observed removing meal trays from rooms on droplet precautions and placing those trays onto the meal cart with other dishes for return to the kitchen. Additionally, staff were observed wearing PPE incorrectly, hand hygiene was not performed during medication administration, and food was transported uncovered through the hallways. Resident identifiers: 16, 143, and 191. Findings included: A. TBP and Droplet Isolation Rooms On 1/10/22 at 9:10 AM, an observation was made of a sign posted at the front entrance desk. The notice was dated January 8, 2022 and stated that the facility was in outbreak status and had COVID positive staff on two hallways in the Skilled Nursing Facility (SNF). On 1/10/22 at 9:26 AM, a interview was conducted with the facility Administrator (ADM). The ADM stated that the facility was currently in outbreak status with 7 staff members testing positive for COVID-19 throughout the building in both the Assisted Living Facility (ALF) and the SNF. The ADM stated that they they were conducting outbreak testing every 3-5 days for all facility staff and residents, and no residents were currently COVID positive. The ADM stated that the outbreak originally began with a resident who contracted it from their family member, and that resident was transferred to a COVID facility for care. On 1/10/22 at 9:55 AM, the ADM clarified and stated that the outbreak originally began on December 20, 2021 with a COVID positive Certified Nurse Aide (CNA) 3. The ADM stated that all residents were tested on [DATE] and none were COVID positive. On 12/25/21 the first resident became symptomatic with a cough and weakness, and subsequently tested positive. This resident was transferred to a COVID facility for care. The ADM stated that all COVID positive residents were transferred out of the facility. The ADM stated that they conducted testing of all residents on the affected unit Floral on 12/25/21 as the resident was isolated to that area. The ADM stated that they conducted contact tracing for any staff that worked on Floral and tested on ly staff that worked on the Floral unit and tested all resident on Floral. The ADM stated that on 1/3/22 a housekeeper (HK) 2 tested positive, but had not worked in 5 days. The ADM stated that the first round of testing ended on January 1/3/21. Then on 1/7/21 a Licensed Practical Nurse (LPN) 1 from Floral complained of a headache. LPN 1 subsequently tested positive for COVID. The ADM stated that around this time she had 3 additional staff on the ALF and 2 staff on the SNF with symptoms that tested negative with the rapid antigen test. The ADM called the local health department and arrangements were made to have all staff members polymerase chair reaction (PCR) tested. From the PCR tests CNA 10 came back positive for COVID and had worked on the Nature unit. The ADM stated that the first round of testing for all residents on the Floral and Nature unit would be conducted today. The ADM stated that all staff were notified on Friday, 1/7/22, to test for the current outbreak. The ADM stated that all residents on the Floral and Nature unit were on quarantine and isolating in their room on contact/droplet precautions. The ADM clarified that the north section of the building was considered the Floral unit and the south section of the building was the Nature unit, and that all of the SNF residents were isolating in their rooms on contact/droplet precautions. The ADM stated that staff entering the rooms should be wearing a gown, gloves, N95, and eye protections. The ADM stated that staff were universally wearing an N95 masks and eye protection. The ADM stated that the rest of the building staff were also wearing an N95 mask and eye protection, and this included the kitchen staff, maintenance staff, and housekeeping staff. The ADM stated that the facility was utilizing reusable washable gowns and they were located on a hook in the resident rooms. The ADM stated that they were changed each shift, and the same staff should be using the same gown throughout the shift. The ADM stated that there were multiple hooks in the resident room if more gowns were needed. The ADM stated that all staff were wearing N95 and eye protection and should be donning gowns and gloves when entering resident rooms. The ADM stated that they were in contingency supply with PPE and the N95 masks could be worn up to 3 times and then discarded if they were not soiled or damaged. The ADM stated that for new admissions they determine vaccination status prior to arrival and the resident had a negative COVID test. The ADM stated that if the new admission was not vaccinated against COVID-19 then they would be placed in isolation on droplet precautions for 7 days. The ADM stated that after day 7 they would test the resident again and if they had a second negative COVID test they could come off of isolation after 7 days. On 1/11/22 at 8:02 AM, the ADM stated that Physical Therapist (PT) 2, CNA 11, and LPN 2 had tested positive on 1/10/22. The ADM stated that the staff were not working yesterday. The ADM stated that all residents had tested negative for COVID. 1. Resident 16 was admitted to the facility on [DATE] with diagnoses of dementia, hemiplegia and hemiparesis following cerebral infarction, hypertension, macular degeneration, hyperlipidemia, hypothyroidism, and osteoporosis. On 1/10/22 at approximately 11:50 AM, an observation was made of resident 16's room. The door was closed and a sign was posted that stated droplet precautions. Instructions on the sign stated, 1.) A. Private room, door may remain open B. Patient must be confined to room 2.) Health Care Workers must wear mask and gloves upon entry to the patient's room 3.) Mask should be worn by all entering the room 4.) Clean hands after removing mask and gloves and before leaving room A PPE cart was located outside of resident 16's room contained gloves, surgical mask, disposable gowns, and red biohazard bags. On 1/10/22 at 12:11 PM, an interview was conducted with CNA 2. CNA 2 stated that isolation precautions were for new residents and residents who had symptoms consistent with COVID-19. CNA 2 stated that resident 16 was symptomatic but she believed the COVID test was negative. CNA 2 stated that they wear disposable gowns for the rooms on droplet precautions. On 1/10/22 at 12:23 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 16 had new onset symptoms of a fever, cough and pain. RN 1 stated that resident 16's rapid antigen test came back negative, and that she had just received the results of the PCR test that morning and it was also negative. RN 1 stated she was not sure why resident 16 was still on droplet precautions, and maybe it was just as an added precaution. RN 1 stated that she would check and let me know. RN 1 stated that resident 16 had been on isolation precautions for 2 days. On 1/10/22 resident 16's medical records were reviewed. Review of resident 16's immunization records documented that resident 16 had received the SARS-CoV-2 dose 1 on 1/15/21, SARS-CoV-2 dose 2 on 2/5/21, and the Pfizer Booster on 10/21/21. Review of resident 16's progress notes revealed the following: a. On 1/9/2022 at 2:45 AM, Fever of 100.3, prn (as needed) tylenol given to decrease fever and rapid Covid-19 test done due to fever and pt (patient) c/o (complaints of) of (sic) 'body pain head to toe that won't go away'. b. On 1/9/2022 at 5:53 AM, tylenol effective, temperature reduced to 98.8. Covid-19 rapid test results negative. Will follow up with DON (Director of Nursing) regarding possibility of getting a PCR due to persisting pt c/o body pain, sore throat, and higher than normal temperature. c. On 1/9/2022 at 10:15 AM, Pt is having several s/sx (signs and symptoms) of a covid-19 infection. Fever, controlled with tylenol. Dry cough, nauseated. Reported to Medical team. Orders received to perform PCR test, d. On 1/9/2022 at 11:30 AM, Obtained COVID-19 PCR Nasopharyngeal sample per orders at 1100 and transported to [local hospital] lab. e. On 1/11/2022 at 1:46 PM, Results received from state lab for PCR done. Resident no longer having symptoms and test negative. Droplet precautions removed. No documentation could be found of laboratory test results for the PCR test nor the rapid antigen test obtained on 1/9/22. On 1/11/22 at 8:50 AM, an observation was made of the Minimum Data Set (MDS) Nurse in resident 16's room. The MDS nurse was located inside resident 16's room at the side of resident 16. Resident 16 was seated in a wheelchair, and the MDS nurse was rubbing resident 16's back with bare hands. The MDS nurse did not have a gown or gloves donned. The MDS nurse was wearing an N95 mask and eye protection. Resident 16's room was observed with signs posted that stated droplet precautions and the PPE cart was located outside of the room. An immediate interview was conducted with the MDS nurse upon exit of resident 16's room. The MDS nurse did not disinfect the eye protection upon exit of resident 16's room. The MDS nurse stated that she was going room to room making rounds to make sure that all residents had their call lights next to them. The MDS nurse stated she was not sure why resident 16 had a droplet precaution sign posted. The MDS nurse stated that if they were providing cares they should be donning PPE for droplet precautions, but that they did not need any other PPE just to enter the resident room. On 1/11/22 at 3:00 PM, an observation was made of resident 16's room without the droplet precaution sign and PPE cart. On 1/11/22 at 3:02 PM, an interview was conducted with RN 2. RN 2 stated that the droplet precaution signs for resident 16 were removed because the dates had passed and they were there longer than they needed to be. RN 2 stated that the droplet precautions were for complaints of nausea and body aches. RN 2 stated that both the antigen and PCR test were negative. RN 2 stated that she could have taken the signs down this morning but she had not gotten around to it yet. RN 2 stated that she would have to ask where resident 16's test results were located. RN 2 stated that when she conducted a rapid antigen test she would write the results down on paper and turn it into the DON and they recorded the information. RN 2 stated that she did not know where that information would be located. RN 2 stated that she currently did not have any residents right now that were exhibiting any signs or symptoms (s/sx) of COVID. RN 2 stated that even resident 16 did not have anymore s/sx of COVID, and that she was no longer nauseated or febrile. RN 2 stated that the aides would report any s/sx to her. RN 2 stated that some residents were assessed daily for lung sounds if they were Medicare. If they meet that criteria then she would listen to their lung sounds. If not, then they would have a respiratory assessment completed weekly. 2. Resident 143 was admitted to the facility on [DATE] with diagnoses of fracture of neck of left femur, repeated falls, type 2 diabetes mellitus, acute respiratory failure, left bundle-branch block, congestive heart failure, hyperlipidemia, and dependence on supplemental oxygen. On 1/10/22 at approximately 11:50 AM, an observation was made of resident 143's room. The door was closed and a sign was posted that stated droplet precautions. Instructions on the sign stated, 1.) A. Private room, door may remain open B. Patient must be confined to room 2.) Health Care Workers must wear mask and gloves upon entry to the patient's room 3.) Mask should be worn by all entering the room 4.) Clean hands after removing mask and gloves and before leaving room A PPE cart was located outside of resident 143's room contained gloves, surgical mask, disposable gowns, and red biohazard bags. On 1/10/22 at 12:11 PM, an interview was conducted with CNA 2. CNA 2 stated that isolation precautions were for new residents and residents who had symptoms consistent with COVID-19. CNA 2 stated that resident 143 was a new admission. CNA 2 stated that they wear disposable gowns for the rooms on droplet precautions. On 1/10/22 at 12:23 PM, an interview was conducted with RN 1. RN 1 stated that resident 143 was a new admit on quarantine. On 1/10/22 at 2:19 PM, an observation was made of resident 143 being wheeled back to their room by Certified Occupational Therapist Assistant (COTA). The resident was observed wearing a surgical mask. The COTA was wearing a N95 mask and eye protection. The COTA did not donn a gown or gloves prior to entering resident 143's room. The COTA assisted resident 143 back to bed. The COTA did not disinfect their eye protection after exiting resident 143's room. An immediate interview was conducted with the COTA upon exit of resident 143's room. The COTA stated that he was just coming back from the therapy gym with resident 143. The COTA stated that resident 143 went to therapy daily in the facility gym. The COTA stated that unless he was providing personal cares he did not need to wear a gown or gloves when working with resident 143. The COTA stated that examples of personal care were assisting resident 143 with toileting, and that he did not do that today. The COTA stated that he did not wear a gown or gloves in the therapy gym either. On 1/10/22 resident 143's medical records were reviewed. Review of resident 143 immunization records documented under SARS-CoV-2 dose 1, Consent Refused. No date was documented. On 12/31/21 resident 143 signed a COVID-19 Vaccination Declination. The form did not document that the resident had received a COVID-19 vaccine prior, or had received passive antibody therapy. Review of resident 143's orders revealed an order for droplet precautions for 14 days that was initiated on 12/31/21 and had an end date of 1/14/22. On 1/11/22 at 11:38 AM, a follow-up interview was conducted with the ADM. The ADM stated that they were down a housekeeper and could not keep up with washing the reusable gowns. The ADM stated that they did not have enough disposable gowns, so they were going to implement universal gowning. The ADM stated that meant that staff would be wearing the same gown throughout the shift unless soiled or damaged. The ADM stated that this did not apply to the rooms on droplet precautions. The ADM stated that those rooms the staff would have to donn an additional disposable gown over the universal gown prior to entering. On 1/11/22 at 3:00 PM, an observation was made of resident 143 without the droplet precaution sign and PPE cart. Resident 143 door was open and a staff member was located at the bedside providing therapy. The staff member was wearing a N95 mask, goggles, reusable gown, and gloves. The staff member did not have a second disposable gown donned over the reusable gown. It should be noted that per the physician orders resident 143 should have been on droplet precautions through 1/14/22. On 1/11/22 at 3:02 PM, an interview was conducted with RN 2. RN 2 stated that the droplet precaution signs for resident 143 were removed because the dates had passed and they were there longer than they needed to be. RN 2 stated that resident 143 was on droplet precautions for new admission, and was admitted on [DATE]. RN stated that resident 143 should be on isolation precautions for 2 weeks, and was taken off of isolation precautions a couple of days short. RN 2 stated she would ask why it was removed. RN 2 stated that she believed that resident 143 had been vaccinated, but had not had both doses. RN 2 stated that the facility policy for new admissions was to check the resident's vaccination status, encourage them to get vaccinated if they were not, and if they were not vaccinated they were placed on contact/droplet precautions for two weeks. RN 2 stated resident 143's PPE cart and droplet sign was removed a couple of days early. RN 2 stated that they monitored for signs and symptoms of COVID daily with temperature checks, and some residents get oxygen saturation but not all residents. RN 2 stated that now that we are on outbreak status she was not sure if they were going to change the monitoring to include more. RN 2 stated that the outbreak status meant they were wearing N95 masks, goggles, gloves, and gowns with all residents. RN 2 stated that since this morning they had received an email that stated that since the community positivity rate had gone up they should be wearing full PPE with all residents. RN 2 stated, to be honest gloves should have been worn with all patient care this morning. RN 2 stated staff should be wearing gowns, gloves, goggles, N95 with all care not just feeding, transferring, and incontinence care. RN 2 stated that there was no additional or different measures or PPE needed for residents on TBP verses other residents in the facility. RN 2 stated maybe an extra mask, because a gown and gloves were implemented for everyone now. On 1/11/22 at 3:55 PM, an interview was conducted with the DON. The DON stated that she along with the facility Infection Preventionist (IP), and MDS Coordinator conducted the antigen testing of all the residents yesterday. The DON stated that the results were documented on a paper and then they were scanned into the residents individual records. The DON stated that she was behind in scanning due to having to help out with staffing shortages from the current outbreak. On 1/12/22 at 10:19 AM, an interview was conducted with the DON and IP. The DON stated that unvaccinated new admissions were placed on quarantine for 14 days and could test out on day 10 if they were not showing and s/sx consistent with COVID and had a negative COVID test. The DON stated that the guidance was provided by the state. The DON stated that droplet precautions PPE utilized was a gown, gloves, mask, and eye protection. The DON stated that all residents were tested prior to admit. The DON stated that they could use a surgical masks to preserve their N95 mask supply if the resident was not symptomatic and on droplet precautions. The DON stated that it was in the contingency supply policy. The DON stated that all PPE was hard to get at the moment. The DON stated that they have been using the contingency PPE supply plan approximately since the county case positivity rate had been going up. The DON stated that the ADM monitored the county positivity rate, and emailed the number to her. The DON could not recall how long the county positivity rate had been above 10%, but that was how they determined how often to schedule the COVID testing for the unvaccinated staff. The DON stated that the county positivity rate was also what they based the use of the surgical mask verses the use of the N95 mask for the TBP rooms. The DON stated that if they were having difficulty obtaining supplies of N95 masks from their vender then they reached out to the health department for additional supplies. The DON stated that they were using surgical masks instead of N95 masks because they did not want to use the N95 mask on asymptomatic cases. The DON stated that the Centers for Disease Control and Prevention (CDC) guidance was to use a N95 or higher if you had the supplies for any suspected or confirmed COVID cases. The DON stated that they currently had supplies of N95 masks and were being supplied supplemental by the health department. The DON stated that for new admissions on droplet precautions they try to have them do therapy in the resident room as much as possible. The DON stated that if they need to go out of the room they maintain social distancing, the resident wore a mask, and the therapist wore a gown, gloves, mask and eye protection. The DON stated that the nursing staff should be monitoring for COVID daily and charting in the Treatment Administration Record (TAR). Monitoring for COVID included daily screening of a temperature check and symptoms of cough, shortness of breath, difficulty breathing, headache, loss of taste or smell and a temperature greater than 100.3 degrees Fahrenheit. The DON stated that the nursing staff should be aware of all of those signs and symptoms and the screening process. The DON stated that if a resident should display any signs staff should do a rapid test, place the resident in quarantine, and notify the DON. The DON stated that a follow-up PCR test may be conducted also. The DON stated that resident 143 was taken off of TBP because she tested negative and it was past day 10. The DON stated that all the licensed nurses and CNAs should know that they should be wearing a gown, gloves, mask and eye protection before entering the resident room. The DON stated that all staff had been provided education on PPE and COVID guidelines and that any updated guidance was emailed directly to the staff. The IP stated that staff should be cleaning eye protection with disinfecting wipes at the end of the shift or if they become visibly soiled, and when exiting a droplet precaution room. The DON stated that rooms on TBP the meal trays should be served on disposable plates with disposable cutlery and disposable cups. The DON stated that they should be discarded in the resident room in the bin and would not be returned to the meal cart or the kitchen for disposal. Review of the facility PPE inventory list revealed a N95 masks quantity of 1675. On 1/13/22 at 9:20 AM, an observation was made of resident 143's room. The droplet precaution sign and PPE cart was located back outside of the resident room. Housekeeper (HK) 1 was observed to perform hand hygiene and donn gloves. HK 1 was wearing a reusable cloth gown, N95 mask and goggles. HK 1 donned a surgical mask over the N95 mask. No additional disposable gown was donned over the reusable gown by HK 1. HK 1 entered resident 143's room with the housekeeping cleaning cart and vacuum. HK 1 was heard vacuuming resident 143's room. HK 1 exited resident 143's room with the cleaning cart and vacuum. HK 1 discarded the gloves and hand hygiene was performed. HK 1 did not disinfect their eye goggles upon exit of droplet precaution room. HK 1 was observed to go directly to room [ROOM NUMBER] with the cleaning cart and vacuum, where the cleaning cart was wheeled inside the resident room for use. On 1/13/22 at 9:39 AM, an interview was conducted with HK 1. HK 1 stated PPE for droplet precaution rooms were N95, goggles, and a gown. HK 1 stated that she wore the same gown into the droplet precaution room that she wore throughout the facility. HK 1 stated that she used clean rags and a clean mop rag for each room. HK 1 stated that she did not know if she had to clean her eye goggles after exiting a droplet precaution room. HK 1 stated that she just cleaned the goggles at the end of the day. On 1/13/22 at 9:47 AM, observed CNA 3 to enter resident 143's room. CNA 3 donned a surgical mask over her N95 mask, a disposable gown over the reusable cloth gown, and gloves. CNA 3 wore eye goggles. CNA 3 exited resident 143's room and placed the residents meal tray on the meal cart. The meal tray was served on regular dishes and not disposable. CNA 3 doffed the surgical mask, gloves, disposable gown and hand hygiene was performed. CNA 3 did not disinfect their eye goggles upon exit of the droplet precaution room. On 1/13/22 at 10:06 AM, an observation was made of PT 1 wheeling resident 143 to the therapy gym. Resident 143 had to be wheeled past another resident to enter the therapy gym and was within six feet of each other. Three other residents were present in the gym at the same time. An immediate interview was conducted with the ADM. The ADM stated she would go to the gym and speak to the therapist immediately. The ADM followed-up and stated that PT 1 knew immediately that resident 143 was not supposed to be out of the room. Review of the facility COVID-19 POLICY & PROCEDURES documented that if both exposure and illness were present that the individual would need to isolate in a private room with the door closed. TBP, including Contact and Droplet were to be implemented and PPE included gown, gloves, mask and eye protection. The policy further documented that N95s should be worn by care staff when caring for COVID positive residents and those who have been exposed to COVID-19. The guidance further stated that new admits would be placed on restrictive interventions for 14 days. The guidance was last updated on November 26, 2021. Review of the facility COVID-19 COHORTING POLICY AND PROCEDURES documented newly admitted residents and residents who have traveled outside the facility to locations that have not followed proper infection control practices will be subject to this 'soft quarantine' for 14 days. Resident room doors will be kept closed unless safety concerns require otherwise. Staff will wear goggles or face shields in addition to surgical masks. The guidance was last updated on November 26, 2021. Review of the CDC guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes documented under New Admissions and Residents who Leave the Facility that all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance further stated that all Healthcare Personnel (HCP) caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). The guidance was last updated on September 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html 3. Resident 191 was admitted to the facility on [DATE] with diagnoses which consisted of rhabdomyolysis, fracture of right humerus, hypertension, repeated falls, acute kidney failure, malignant neoplasm of skin of nose, mild cognitive impairment, anemia, and major depressive disorder. On 1/10/22 at 12:16 PM, an observation was made of resident 191's room. The door was closed and a sign was posted that stated droplet precautions. Instructions on the sign stated, 1.) A. Private room, door may remain open B. Patient must be confined to room 2.) Health Care Workers must wear mask and gloves upon entry to the patient's room 3.) Mask should be worn by all entering the room 4.) Clean hands after removing mask and gloves and before leaving room A PPE cart was located outside of resident 191's room contained gloves, N95 masks, disposable gowns, red biohazard bags, and alcohol based hand rub (ABHR). On 1/11/22 resident 191's medical records were reviewed. Review of resident 191's immunization records documented under SARS-CoV-2 dose 1, Consent Refused. No date was documented. On 1/1/22 resident 191 signed a COVID-19 Vaccination Declination. The form did not document that the resident had received a COVID-19 vaccine prior, or had received passive antibody therapy. Review of resident 191's orders revealed an order for droplet precautions for 14 days that was initiated on 12/28/21 and had an end date of 1/11/22. On 1/10/22 at 12:22 PM, an interview was conducted with CNA 5. CNA 5 stated the facility was in outbreak status and all residents were being quarantined for 5 days. CNA 5 stated the resident 11 was a new admission. CNA 5 stated she was not sure how long resident 191 would be in quarantine. On 1/10/22 at 1:04 PM, CNA 5 delivered the lunch meal tray to resident 191. CNA 5 donned a gown and gloves in addition to the N95 mask and eye protection that was worn. CNA 5 delivered the meal tray to the droplet precaution room on a regular uncovered plate, no disposable service ware was used. CNA 5 did not disinfect their eye protection upon exit of the droplet precaution room. On 1/10/22 at 2:34 PM, an observation was made of CNA 9 entering resident 191's room without donning a gown. CNA 9 was wearing a surgical mask and eye protection. CNA 9 exited resident 191's room at 2:37 PM with a meal tray. CNA 9 carried the uncovered tray down the entire hallway and around the corner where the meal cart was located. Resident 191's lunch meal tray was placed on the meal cart with all the other meal trays for return to the facility kitchen. B. PPE Usage On 1/10/22 at approximately 9:15 AM, an observation was made of a CNA 2 seated in the dining room next to a resident assisting with dining. The CNA was observed with their eye protection placed on top of their head and their surgical mask was down below their nose. On 1/10/22 at 9:55 AM, a interview was conducted with the facility ADM. The ADM stated that communal dining in the dining room had been suspended during the outbreak and all residents were eating in their rooms unless they required dining assistance. On 1/10/22 at 3:33 PM, a phone interview was conducted with resident 3's family member. Resident 3's family member stated his spouse had observed the CNA's taking off their masks while in resident 3's room multiple times. On 1/11/22 at 3:07 PM, an interview was conducted with Housekeeper (HK) 2. HK 2 was wearing a gown, gloves, eye protection and an N95 mask. HK 2 stated she cleaned resident room's daily and cleaned common areas weekly. HK 2 stated she wasn't told much about the need to wear a gown. HK 2 stated she was just handed a gown and told to put it on. HK 2 stated she had been wearing the gown the whole shift. HK 2 stated she had not been told if she needed to change her gown based on what room she went in. HK 2 stated she had to wear gloves while in resident rooms. On 1/11/22 at 3:20 PM, an interview was conducted with CNA 8. CNA 8 stated she did not know why the staff were wearing gowns. CNA 8 stated she was told to wear gloves, eye protection and a mask to go into a resident room. CNA 8 stated she was not told when to change the gown or how often. CNA 8 stated she thought it was to protect the resident's and staff. On 1/11/22 at 3:27 PM, an interview was conducted with CNA 7. CNA 7 stated she did not know why staff were wearing gowns. CNA 7 stated she thought it was for extra precautions. CNA 7 stated if a resident was positive the staff would use the gowns in the room. CNA 7 stated all residents were negative on that hallway. CNA 7 stated all residents were tested on the previous evening before she left between 6:30 and 6:45 PM. On 1/12/22 at 8:33 AM, an interview was conducted with the Housekeeping Manager (HKM). HKM stated staff were wearing gowns, goggles, and N95 masks. HKM stated staff were wearing gloves only for personal cares of the residents. HKM stated he avoided newly admitted resident rooms to avoid having to change his gown. HKM stated that facility started using gowns and N95 masks yesterday due to the high county positivity rate. C. Medication Administra[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review it was determined, for 1 of 32 sample residents, that the facility did not immediately consult with the resident's physician. Specifically, a resident did not have physician notification when antihypertensive medications were held, with patient re-occurring hypotension. Resident identifier: 31. Findings include: 1. Resident 31 was admitted to the facility on [DATE], she was sent out to the hospital for a gastrointestinal bleed, and readmitted on [DATE] with diagnoses which included malignant ovarian cancer, gastrointestinal hemorrhage, sepsis due to Escherichia coli, urinary tract infection, aftercare following surgery for neoplasm, aftercare following surgery on the genitourinary system, speech and language deficits related to stroke, atrial fibrillation, severe malnutrition, hypotension, hyperlipidemia, gastro-esophageal reflux disease, hypothyroidism, and major depressive disorder. Resident 31's medical record was reviewed on 9/25/19. A physicians order was entered on 8/9/19 for Diltiazem 180 MG (milligrams) by mouth one time a day for A-fib. Resident 31 was discharged to the hospital and readmitted on [DATE] with an updated order for Diltiazem 120 MG Give 120 mg by mouth one time a day for Hypertension. A review of resident 31's Medication Administration Record (MAR) for August and September 2019 revealed that resident 31's diltiazem was held on the following days without blood pressure parameters or physician orders to hold: a. 9/14/19 held rationale documented as Med withheld due to low blood pressure. Blood pressure documented as 80/45. No MD (Medical Doctor) notification documented. b. 9/21/19 held rationale documented as Med withheld due to low blood pressure. No blood pressure or MD notification was documented. c. 9/22/19 held rationale documented as Vitals Outside of Parameters for Administration. No blood pressure or MD notification was documented. d. 9/23/19 held rationale documented as Vitals Outside of Parameters for Administration. Blood pressure documented as 71/77. No MD notification documented. e. 9/24/19 held rationale documented as Vitals Outside of Parameters for Administration. Blood pressure documented as 77/46. No MD notification documented. On 9/25/19 at 2:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did have standing orders to hold a blood pressure medication per the facility Vital Sign Policy. The DON then stated that the standing order parameters were just suggestions for the nurse if they did not feel comfortable administering a medication because of low blood pressure. The DON stated that if the nurse did hold the medication then that nurse should contact the doctor for an order. The DON stated that she knew that resident 31's blood pressures had been trending low, but that resident 31 was asymptomatic so the MD had not been notified. A copy of the facility Vital Sign Policy was obtained and revealed: Purpose: To recognize physiological changes in resident condition and intervene quickly Procedure: Notify resident's primary care physician, hospice, or the facility medical director within a timely manner for any of the following values: - Blood pressure: systolic blood pressure less than 90 mmHg or greater than 180 mmHg or diastolic blood pressure greater than 110 mmHg. - If medication is held due to abnormal vital signs and no physician set parameter nurse must notify MD and obtain parameters if desired. Further review of resident 31's August and September 2019 MAR's revealed blood pressures below the set policy values without MD notification on the following days: a. 8/31/19 blood pressure documented as 80/52. Diltiazem was administered. b. 9/11/19 blood pressure documented as 83/52. Diltiazem was refused. c. 9/17/19 blood pressure documented as 72/47. Diltiazem was administered. d. 9/19/19 blood pressure documented as 77/52. Diltiazem was administered. e. 9/20/19 blood pressure documented as 88/59. Diltiazem was administered. On 9/26/19 at 8:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that if the resident's blood pressure was low and the nurse needed to hold the medication, then the nurse needed to call the MD for an order to hold the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for, 2 of 32 sample residents, that the facility did not provide appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, residents were not offered assistance with their meals. Resident identifiers: 2 and 19. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included weakness, seizures and hemiplegia and hemiparesis following a cerebral infarction. On 9/26/19 at 9:32 AM, an observation was made of resident 2. Resident 2 was in her room sitting in her wheelchair. Resident 2 was observed to have a pillow on her lap and a divided plate on the pillow. Resident 2 was observed to be feeding herself with a fork. Resident 2 had an overbed table placed to the left side of her body. Resident 2 stated that she was unable to pick up her oatmeal or drinks which were observed on the overbed table. Resident 2 was observed to reach to the bedside table with her right hand and was unable to reach her drinks or oatmeal. At 9:45 AM, an observation was made of Certified Nursing Aide (CNA) 2 walking by resident 2's room. CNA 2 did not enter resident 2's room. At 10:00 AM, CNA 2 was observed to enter resident 2's room. Resident 2 asked CNA 2 to put her oatmeal in her divided plate. Resident 2's medical record was reviewed on 9/24/19. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 2 required supervision with set up assistance for eating. A care plan dated 9/7/18 and updated on 9/11/19 revealed, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) weakness and has contracture to left hand on admission. A goal developed was The resident will maintain current level of ADL function through the review date. One of the interventions developed was, EATING: The resident requires set up assistance by (1) staff to eat. Prefers plate divider. A nutrition care plan dated 9/14/18 and updated on 6/17/19 revealed, The resident has nutritional problem (sic) or potential nutritional problem due to CVA (cerebrovascular accident) and depression. The goal developed was Weight should remain stable . One of the interventions developed was Provide level of assistance needed to facilitate good oral intake. On 9/26/19 at 10:10 AM, CNA 2 was interviewed. CNA 2 stated that CNA 3 dropped of resident 2's breakfast meal that day. CNA 2 stated that resident 2 needed her meals set-up but resident 2 was able to feed herself. CNA 2 stated that resident 2's left arm was paralyzed and she was unable to use it. CNA 2 stated that resident 2's bedside table should be on the right side so she can reach items on the bedside table. CNA 2 stated that resident 2 was unable to reach her drinks or items on the bedside table that was on her right side. CNA 2 stated that she placed resident 2's oatmeal in her divided plate for her to be able to eat. On 9/26/19 at 11:00 AM, CNA 1 was interviewed. CNA 1 stated that usually resident 2 only needed set up assistance and she was able to eat with her right hand. CNA 1 stated when she set up resident 2's meals she made sure everything was cut up and she had everything within her reach. CNA 1 stated that sometimes the overbed table was placed in front of the resident to the left so she could reach the things on the table. CNA 1 stated that resident 2 would not be able to reach things placed on the bedside table that were on the left side. CNA 1 stated that a family member was in resident 2's room during meals. CNA 1 stated staff encourage resident 2 to eat in the dining room when her family was not in her room. CNA 1 stated that when a family member was not in her room the staff left resident 2's door open and checked on her. On 9/26/19 at 11:15 AM, CNA 3 was interviewed. CNA 3 stated that resident 2 was able to eat independently after staff provided set-up. CNA 3 stated that resident 2 used a divided plate on top of a pillow on her lap. CNA 3 stated that the resident needed her food cut up and her utensils out of the napkin. CNA 3 stated that, Her left side was the affected side. CNA 3 stated that resident 2 had a stroke and was unable to use her left side. CNA 3 stated that resident 2 was able to do everything with her right hand for meals. CNA 3 stated that resident 2 did not need to be checked on during meals. CNA 3 stated that once she is set up, she is good to go. CNA 3 stated that resident 2 was able to reach over her left side to reach drinks. CNA 3 stated that 90% of the time family is in there to help her. CNA 3 stated that As long as everything is close to her and around her she can get it. On 9/26/19 at 11:35 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 2 required set-up assistance with eating. The DON stated that resident 2 required her food to be cut up. The DON stated that resident 2 sat with her right side to the table in the dining room so she was able to reach everything. The DON stated that she did not know what type of assistance resident 2 needed in her room because she had only assisted her in the dining room. 2. Resident 19 was admitted to the facility on [DATE] with diagnoses that included weakness, stress fracture, major depressive disorder, pain, and constipation. On 9/23/19, resident 19's medical record was reviewed. An admission assessment dated [DATE] indicated that resident 19 was highly impaired in her ability to see in adequate light with glasses. Resident 19's admission MDS assessment dated [DATE] indicated that resident 19 required supervision with eating with setup help only. The MDS indicated that resident 19's vision was adequate. Resident 19's quarterly MDS assessment dated [DATE] indicated that the resident required extensive one person physical assistance with eating. The MDS indicated that resident 19's vision was adequate. A care plan dated 2/7/19 indicated that resident 19 has an ADL self-care performance deficit related to femur fracture and surgery repair. The interventions included The resident requires set up to limited assistance by (1) staff to eat. [Note: The care plan had not been updated to indicate resident 19's current level of assistance as documented in the 8/2/19 MDS. In addition, no care plan had been developed regarding resident 19's highly impaired vision.] A weekly skilled assessment dated [DATE] indicated that resident 19 was oriented to person, but not place. time or situation due to short-term memory impairment, impaired decision making ability, confusion, delusions, and being easily distracted. The assessment also indicated that resident 19 required assistance with eating. On 8/2/19 a Brief Interview for Mental Status (BIMS) was completed for resident 19. The BIMS score was 5, indicating a severe impairment. On 9/23/19, an observation was made of the lunch meal in the main dining room. The following observations were made of resident 19: a. Resident 19 was served her meal at 12:18 PM. b. At 12:19 PM, CNA 6 was observed to assist resident 19 with multiple bites of food, by picking up the resident's fork and feeding the resident. CNA 6 then assisted a second resident until 12:22 PM. At 12:22 PM, resident 22 arrived and sat between resident 19 and the second resident. c. While CNA 6 was assisting the second resident, resident 19 was observed to attempt to feed herself. She was able to bring the fork to her mouth, but was not able to place more than a pea-sized amount of food on her fork. d. at 12:25 PM, CNA 6 then returned to resident 19. CNA 6 fed resident 19 multiple bites of food by scooping the food onto a fork and placing the forkful of food into resident 19's mouth. CNA 6 then returned to the second resident. e. At 12:28 PM, CNA 6 again returned to assist resident 19, and assisted for approximately 2 minutes. f. At 12:36 PM, CNA 6 asked CNA 3 to help resident 19 because she's not eating. g. At 12:38 PM, CNA 3 asked resident 19, do you need some help?. Resident 19 stated, I can't see what I'm doing. At that point CNA 3 sat next to resident 19 and assisted her one on one until she was finished with her meal at 12:47 PM. Throughout the observation, when resident 19 would attempt to feed herself with her fork, she was unable to place more than a pea-sized amount of food on her fork before bringing the fork to her mouth. The resident also had difficulty with being able to always successfully bring the utensil to her mouth. CNA charting indicated that resident 19 was documented as only receiving limited assistance for this meal. On 9/24/19, an observation was made of the breakfast meal in the main dining room. Resident 19 had a staff member seated next to her, and the staff member was providing one on one assistance throughout the meal. CNA charting indicated that resident 19 was documented as only receiving limited assistance for this meal On 9/25/19, an observation was made of the lunch meal in the main dining room. The following observations were made of resident 19: a. Resident 19 was served at 12:12 PM. Resident 19 was observed to attempt to feed herself with her fork, but was observed to have the same difficulty in placing food on her fork and/or bringing the fork to her mouth as she had experienced on 9/23/19. b. At 12:22 PM, the resident was able to find the roll on her plate using her fork, but was unable to bring it to her mouth using just the fork. She then brought the roll to her mouth using both a fork and her hand to stabilize the roll. c. At 12:30 PM, a staff member asked resident 19 if she was doing okay to which resident 19 nodded her head. d. At 12:40 PM, resident 19 placed her napkin on the table, and pushed her wheelchair away from the table. Resident 19 did not make any further attempts to feed herself, and was wheeled out of the dining room at 12:46 PM. Resident 19 was observed to have consumed approximately 30 percent of her meal. CNA charting indicated that resident 19 was documented as receiving extensive assistance for this meal. On 9/26/19, an observation was made of the breakfast meal in the main dining room. Resident 19 had a staff member seated next to her, and the staff member was providing one on one assistance throughout the meal. CNA charting indicated that resident 19 was documented as being completely dependent on staff for this meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, 1 of 32 sample residents was not seen by the physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses that included senile debility. On 9/23/19, resident 22's medical record was reviewed. On 4/29/19, resident 22 was seen by her primary care physician. No documentation could be located to indicate that resident 22 had been seen by her physician since that date, nearly 5 months prior. On 9/26/19, an interview was conducted with the Director of Nursing (DON). The DON stated that she had contacted the physician's office and left a message for them to provide documentation that the resident had been seen. As of 10/1/19, no additional information had been submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 32 sample residents, that the facility did not ensure that a resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued or any combinations of the reasons above. Specifically, the facility did not notify the physician of blood pressures outside facility protocol parameters. Additionally, the facility did not monitor potassium levels of a resident taking a potassium wasting diuretic. Resident identifier: 31. Findings include: Resident 31 was admitted to the facility on [DATE], she was sent out to the hospital for a gastrointestinal bleed, and readmitted on [DATE] with diagnoses which included malignant ovarian cancer, gastrointestinal hemorrhage, sepsis due to Escherichia coli, urinary tract infection, aftercare following surgery for neoplasm, aftercare following surgery on the genitourinary system, speech and language deficits related to stroke, atrial fibrillation, severe malnutrition, hypotension, hyperlipidemia, gastro-esophageal reflux disease, hypothyroidism, and major depressive disorder. Resident 31's medical record was reviewed on 9/25/19. A. On 9/14/19 a physician's order was entered for Lasix Tablet 20 MG (milligrams) (Furosemide) Give 20 mg by mouth one time a day for diuretic. According to the Wolters-Kluwer 2016 Nursing Drug Handbook; pages 655-658; considerations when giving furosemide, which is a potassium wasting diuretic, Black Box Warning: Drug is a potent diuretic and can cause severe diuresis with water and electrolyte depletion.Watch for signs of hypokalemia. Consult prescriber and dietician about high potassium diet or potassium supplements. [Note: Hypokalemia is a condition of potassium deficiency. No orders for a high potassium diet or potassium supplement were started.] A review of resident 31's lab results revealed that her potassium level on 8/15/19 was 3.3 mmol/L (millimole/liter), and on 8/19/19 her potassium level was 3.4 mmol/L. Normal potassium level range is 3.5-5.0 mmol/L. Resident 31's potassium level had not been monitored since her readmission to the facility and the new order for Lasix was started. According to Laboratory and Diagnostic Tests with Nursing Implications Eight Edition, considerations for decreased potassium levels include: . Observe for signs and symptoms of hypokalemia, such as vertigo (dizziness), hypotension, cardiac dysrhythmias, nausea, vomiting, diarrhea, abdominal distention, decreased peristalsis, muscle weakness, and leg cramps. Monitor serum potassium level in clients receiving potassium-wasting diuretics. On 9/25/19 at 2:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that potassium supplements were given with a potassium wasting diuretic only when the physician ordered them. The DON stated that she was not aware that resident 31 had a low potassium level prior to starting Lasix, and stated that she did not know if resident 31's potassium was being monitored. On 9/26/19 at 8:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that when a resident was on a diuretic staff should monitor for edema, urine output, blood pressure, heart rate, and lung sounds. LPN 3 also stated that since Lasix was a potassium wasting diuretic it should be given with a potassium supplement and the facility should also monitor potassium levels. On 9/26/19 at 9:48 AM, a follow up interview was conducted with the DON. The DON stated that she talked with the doctor about resident 31's edema and lasix, stated that the MD ordered a BMP (basic metabolic panel) and BNP (brain natriuretic peptide) labs as well as stopped resident 31's cardiac medication. B. A physician's order was entered on 8/9/19 for dilTIAZem HCl (hydrochloride) ER (extended release) Beads Capsule Extended Release 24 Hour 180 MG Give 1 capsule by mouth one time a day for A-fib. Resident 31 was discharged to the hospital and readmitted on [DATE] with an updated order for dilTIAZem HCl ER Capsule Extended Release 24 Hour 120 MG Give 120 mg by mouth one time a day for Hypertension. A review of resident 31's Medication Administration Record (MAR) for August and September 2019 revealed that resident 31's diltiazem was held on the following days without blood pressure parameters or physician orders to hold: a. 9/14/19 held rationale documented as Med withheld due to low blood pressure. Blood pressure documented as 80/45. No MD (Medical Doctor) notification documented. b. 9/21/19 held rationale documented as Med withheld due to low blood pressure. No blood pressure or MD notification was documented. c. 9/22/19 held rationale documented as Vitals Outside of Parameters for Administration. No blood pressure or MD notification was documented. d. 9/23/19 held rationale documented as Vitals Outside of Parameters for Administration. Blood pressure documented as 71/77. No MD notification documented. e. 9/24/19 held rationale documented as Vitals Outside of Parameters for Administration. Blood pressure documented as 77/46. No MD notification documented. On 9/25/19 at 2:41 PM, an interview was conducted with the DON. The DON stated that the facility did have standing orders to hold a blood pressure medication per the facility Vital Sign Policy. The DON stated that if the blood pressure was below their parameters then the nurse would hold the medication and notify the MD prior to administering the next dose. The DON then stated that the standing order parameters were just suggestions for the nurse if they did not feel comfortable administering a medication because of low blood pressure. The DON stated that if the nurse did hold the medication then that nurse should contact the doctor for an order. The DON stated that the nurse management audited the MAR weekly and completed one on one education with the nurses if they noticed an issue. The DON stated that she knew that resident 31's blood pressures had been trending low, but that resident 31 was asymptomatic so the MD had not been notified. A copy of the facility Vital Sign Policy was obtained and revealed: Purpose: To recognize physiological changes in resident condition and intervene quickly Procedure: Notify resident's primary care physician, hospice, or the facility medical director within a timely manner for any of the following values: - Blood pressure: systolic blood pressure less than 90 mmHg (millimeters of mercury) or greater than 180 mmHg or diastolic blood pressure greater than 110 mmHg. - If medication is held due to abnormal vital signs and no physician set parameter nurse must notify MD and obtain parameters if desired. Further review of resident 31's August and September 2019 MAR's revealed blood pressures below the set policy values without MD notification on the following days: a. 8/31/19 blood pressure documented as 80/52. Diltiazem was administered. b. 9/11/19 blood pressure documented as 83/52. Diltiazem was refused. c. 9/17/19 blood pressure documented as 72/47. Diltiazem was administered. d. 9/19/19 blood pressure documented as 77/52. Diltiazem was administered. e. 9/20/19 blood pressure documented as 88/59. Diltiazem was administered. On 9/26/19 at 8:02 AM, an interview was conducted with LPN 3. LPN 3 stated that the facility did not have any standing order parameters to hold blood pressure medications. LPN 3 stated that if the resident's blood pressure was low and the nurse needed to hold the medication, then the nurse needed to call the MD for an order to hold the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 10 was admitted on [DATE] with diagnoses which included weakness, hip fracture, pelvic fractures, hyperlipidemia, major depressive disorder, vitamin deficiency, hypertension, constipation, and pain. Resident 10's medical record was reviewed on 9/25/19. A physician's order for Xanax 0.125 mg (milligram) at bedtime for insomnia was started on 4/11/19. Wolters-Kluwer 2016 Nursing Drug Handbook; pages 107-108; listed anxiety and panic disorders as the only approved diagnoses for use of Xanax. [Note: Resident 10 did not have a diagnosis of anxiety, panic disorder, or insomnia.] On 9/26/19 at 11:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that Xanax was an antianxiety medication, and she would expect someone who was taking Xanax to have a diagnosis of anxiety. The DON further stated while she knew some people used Xanax for insomnia, she did not believe it was an approved diagnosis and that other medications such as melatonin should be tried first. [Note: No melatonin or other medication was given to resident 10 to help treat insomnia.] Based on interview and record review, the facility did not ensure that 2 of 32 sample residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; and that Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; and residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days. Specifically, residents were prescribed psychotropic medications without indication for use, monitoring, and in excess of 14 days on an as needed basis. Resident identifiers: 10 and 19. Findings include: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses that included weakness, stress fracture, major depressive disorder, pain, and constipation. On 9/23/19, resident 19's medical record was reviewed. On 2/7/19 a Pre-admission Screening Resident Review (PASRR) was completed for resident 19. The PASRR did not indicate that resident 19 had any psychiatric diagnoses such as anxiety. a. Review of resident 19's physician orders revealed that on 5/25/19 Seroquel 25 milligrams (mg) was prescribed for a diagnosis of sleep. On 8/1/19, the diagnosis listed on the Seroquel was changed to delusions with anxiety do not remove or decrease. The September 2019 Medication Administration Record (MAR) indicated that resident 19's physician had ordered that resident 19's behaviors of delusions or hallucinations were to be monitored. The MAR indicated that nurses were to document Y (yes) if the behaviors were monitored and none of the above were observed. Nurses were to document N (no) if the behaviors were monitored and any of the above were observed, and make a note in the progress notes. The MAR indicated that nurses did not enter in either Y or N to indicate the presence or lack of behaviors, but instead placed a check mark on the MAR, the meaning of which was unclear. The Psychotropic Drug Review dated 8/19/19 for resident 19 indicated that resident 19 had experienced 1 delusion and no behaviors in the last 30 days. No documentation could be located to indicate other non-pharmacological interventions were attempted prior to administering Seroquel. In addition, no monitoring of delusions/hallucinations was documented prior to administering Seroquel. b. Review of resident 19's physician orders also revealed that on 4/25/19, Xanax 0.25 mg every 24 hours as needed (prn) was prescribed for a diagnosis of anxiety. On 7/5/19, the Xanax administration was changed to 0.25 mg daily and 0.25 mg every 8 hours prn. [Note: Resident 19 did not have a diagnosis of anxiety listed in her medical record.] Review of the September 2019 MAR revealed that resident 19 had received 10 of the prn doses of Xanax as of 9/25/19. The September 2019 MAR indicated that resident 19's physician had ordered that resident 19's behaviors of verbalized anxiety or restlessness were to be monitored. The MAR indicated that nurses were to document Y if the behaviors were monitored and none of the above were observed. Nurses were to document N if the behaviors were monitored and any of the above were observed, and make a note in the progress notes. The MAR indicated that nurses did not enter in either Y or N to indicate the presence or lack of behaviors, but instead placed a check mark on the MAR on 38 occasions during the month of September 2019, the meaning of which was unclear. The Psychotropic Drug Review dated 8/19/19 for resident 19 indicated that resident 19 had experienced no episodes of verbalized anxiety and 5 episodes of restlessness in the last 30 days. The document also indicated that resident 19 had received 9 prn doses of Xanax in the last 30 days. No documentation could be located to indicate other non-pharmacological interventions were attempted prior to administering Xanax In addition, no monitoring of verbalized anxiety and restlessness was documented prior to administering Xanax. On 9/26/19 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that on multiple occasions resident 19 was wandering throughout the facility looking for her truck because she was in prison and wanted to leave. The DON did not know why the behaviors or other interventions had not been documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 of 32 sample residents was free of significant medication errors. Specifically, a resident with thrush did not receive her medication as prescribed. Resident identifier: 95. Findings include: Resident 95 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare, hypertension, Crohn's disease, anxiety, hereditary deficiency of other clotting factors, and major depressive disorder. On 9/24/19 at 10:00 AM, an interview was conducted with resident 95. Resident 95 stated that she did not think facility staff were communicating well with each other or the physicians. Resident 95 stated that she told facility staff on 9/20/19 that she felt like she had thrush. Resident 95 stated that a nurse came in and looked at her mouth and throat and stated oh yes, you do have thrush. Resident 95 stated she was not sure if she had received the medication for her thrush yet. On 9/23/19, resident 95's medical record was reviewed. Progress notes for 9/20/19 through 9/23/19 did not reveal any information regarding resident 95's thrush symptoms or communication with the physician, until 9/23/19. On 9/23/19 at 6:31 PM, facility staff entered a progress note that stated, Diflucan 100mg (milligrams) PO (by mouth) daily x (for) 3 days for thrush. Review of resident 95's September 2019 Medication Administration Record (MAR) was reviewed. The MAR indicated that resident 95 received her first dose of Diflucan on 9/23/19 at 9:00 PM. On 9/26/19 at 10:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he had worked on 9/21/19 and was assigned to care for resident 95 that day. LPN 1 stated that he had spoken with resident 95 regarding her symptoms of thrush on 9/21/19. LPN 1 stated that he and 2 students had looked at resident 95's throat and assessed her as having symptoms consistent with thrush. LPN 1 stated that he thought we got the order for a medication to treat resident 95's thrush. LPN 1 stated that he told the charge nurse about it and he thought that the charge nurse entered the physician's order, but maybe the charge nurse thought LPN 1 was going to enter it. LPN 1 stated that the medication the physician prescribed was Diflucan and it arrived the night of 9/21/19. LPN 1 stated he was not sure why resident 95 was not administered the Diflucan before 9/23/19. On 9/26/19 at 11:30 AM, an interview was conducted with the DON regarding the delay in treating resident 95's thrush. The DON stated that the resident had brought that to her attention earlier that day and staff would be addressing her concern.

**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 and secure 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 medication. Specifically, all glucose control solutions in the facility were expired. Findings include: 1. On [DATE] at approximately 8:00 AM, an observation was made of the Orchid medication cart. The glucose control solution was found to have a manufacturer's expiration date of [DATE], although the box had a 'date opened' written on it of [DATE]. The glucose control solution was then observed in the Lotus medication cart and was also found to have an expiration date of [DATE]. [Note: the glucose control solution was used to test accurate functioning of the glucose meter and test strips.] On [DATE] at 8:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that the glucose control solution should be thrown away thirty days after the box was opened. LPN 4 verified that the manufacturer's expiration date was [DATE], and that the glucose control solution should not have been used past that date. LPN 4 stated that if the solution was expired, then it could lead to the glucometers being calibrated incorrectly and report incorrect blood glucose levels. LPN 4 stated that the glucometers were tested and calibrated every night using the glucose control solution that was expired. On [DATE] at approximately 8:40 AM, an observation was made of the Nature and Element medication carts. The glucose control solution was found to have a manufacturer's expiration date of [DATE]. An additional observation of the medication rooms where extra supplies were stored revealed that all glucose control solutions in the facility had manufacturer's expiration dates of [DATE]. On [DATE] at 8:43 AM, an interview was conducted with LPN 2. LPN 2 verified that all of the glucose control solutions had manufacturer expiration dates of [DATE]. A review of the glucose control solution manufacturer manual found at https://www.medline.com/media/catalog/Docs/MKT/LIT715R_MAN_EvenCare%20ProView%20In-Serv.pdf revealed important instructions for use on page 8 of the manual . Control solutions are good three months after opening date or until the last day of the month of expiration, whichever comes first. On [DATE] at 8:39 AM, an interview was conducted with the Director of Nursing (DON). The DON verified that all glucose control solutions in the facility were expired. The DON stated that with expired glucose control solution being used to calibrate the glucometers it would probably show inaccurate results on the glucometer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 32 sample residents, that the facility did not obtain laboratory (lab) services to meet the needs of its residents. Specifically, a resident had an order to obtain a Urine Analysis (UA) with Culture and Sensitivity (C&S) and they were not completed. Resident identifier: 31. Findings include: 1. Resident 31 was admitted to the facility on [DATE], she was sent out to the hospital for a gastrointestinal bleed, and readmitted on [DATE] with diagnoses which included malignant ovarian cancer, gastrointestinal hemorrhage, sepsis due to Escherichia coli, urinary tract infection, aftercare following surgery for neoplasm, aftercare following surgery on the genitourinary system, speech and language deficits related to stroke, atrial fibrillation, severe malnutrition, hypotension, hyperlipidemia, gastro-esophageal reflux disease, hypothyroidism, and major depressive disorder. Resident 31's medical record was reviewed on 9/24/19. A nurses' note dated 8/30/19 documented Resident had appointment with [MD 1]; received following orders. 1: UA (urine analysis) w/C&S (with culture and sensitivity). A review of resident 31's Treatment Administration Record (TAR) for August 2019 revealed that an order was entered for a UA w/C&S related to urinary tract infection symptoms on 8/30/19. Further review revealed no documentation that this order was completed. A review of all of resident 31's lab results did not indicate any UA's completed during that time. On 9/25/19 at 2:41 PM, an interview was conducted with the Director of Nursing (DON). The DON reviewed the facility records and was unable to verify that this order had been completed. On 9/26/19 at 9:49 AM, a follow up interview was conducted with the DON. The DON stated that after further investigation, it was found that the lab was not completed as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined for, 2 of 32 sample residents, the facility did not ensure each resident received food that accommodated their allergies, intolerances and preferences. Specifically, residents complained their preferences were not honored. Resident identifiers: 2 and 11. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included weakness, hemiplegia, hemiparesis following a cerebral infarction and seizures. On 9/24/19 at 9:45 AM, an interview and observation was made of resident 2. Resident 2 was observed to be eating in her room. Resident 2's family member was in her room with her. Resident 2 stated that her food preferences were not honored. Resident 2 stated that she was not served oatmeal for breakfast. An observation was made of resident 2's meal tray and there was no bowl or oatmeal on her tray. Resident 2's family member was observed to ask the Certified Nursing Assistant (CNA) for oatmeal. The CNA was observed to leave the room and returned with oatmeal for resident 2. Resident 2's family member stated that he had provided a breakfast menu to the kitchen multiple times. Resident 2's medical record was reviewed on 9/26/19. A nutrition care plan dated 9/14/18 and updated on 6/17/19 revealed The resident has nutritional problem (sic) or potential nutritional problem due to CVA (cerebrovascular accident) and depression. The goal developed was, Nutrient needs should be met through oral intake. An intervention developed was, Honor food and dining preferences. A dietary profile was completed September 2018. The dietary profile revealed that resident had an allergy or intolerance to raw onions and raw broccoli. There were no new preferences documented in resident 2's medical record since admission. On 9/26/19 at 11:00 AM, an interview was conducted with CNA 1. CNA 1 stated that she was aware that resident 2 was unable to eat raw onions and broccoli. CNA 1 stated that the DM talked with residents and wrote dislikes and allergies on the meal cards. On 9/26/19 at 9:32 AM, a follow up interview was conducted with resident 2. Resident 2 stated that she did not get sausage that morning. Resident 2 stated that she was unable to eat wheat bread because it gave her terrible gas pains, indigestion and diarrhea. Resident 2 stated she was served a sandwich yesterday at lunch with wheat bread. Resident 2's meal ticket paper was reviewed. There was no information documented that resident 2 was unable to have wheat bread. On 9/26/19 at 10:15 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 2 did not have any food allergies and was not aware of any foods she was unable to eat. 2. On 9/24/19 at 2:30 PM, an interview was conducted with a group of residents as part of a resident council. During the council, resident 11 stated that he had asked facility staff on multiple occasions for more cereal, but they still only brought one bowl. In addition, the resident stated that he continually requested toast but that the staff don't get your order right. On 9/26/19 at 11:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Dietary Manager (DM) did a dietary profile when residents were admitted . The DON stated that she was not sure of how often food preferences were updated. On 9/26/19 at 1:49 PM, an interview was conducted with the DM. The DM stated he obtained resident preferences and allergies when he completed a dietary profile assessment upon admission. The DM stated that he did not re-evaluate resident food preferences because most residents discharged within 2 months of admission. The DM stated that if a resident had a preferences that were not on the dietary profile then, CNAs communicated that to the kitchen staff. The DM stated he was not aware of a policy and procedure as to when to reassess resident's preferences.

Based on interview and record review it was determined that for 1 out of 32 sample residents, the facility did not offer a second pneumococcal immunization. Resident identifier: 17. Findings include: 1. Resident 17 was admitted to the facility 2/3/18 with diagnoses that included weakness, displaced intertrochanteric fracture of the right femur, metabolic enchephalopathy, acute posthemoragic anemia, psychotic disorder with delusions due to known physiological condition, dementia with lewy bodies and unspecified vitamin deficiency. On 9/25/19, resident 17's medical record was reviewed. An immunization administration record indicated that resident 17 had received a Prevnar 13 pneumococcal immunization on 10/28/17, prior to his current admission. The immunizations tab of the facility's electronic medical record indicated that resident 17 had received the Prevnar 13 pneumococcal immunization on 10/28/17. Per the Centers of Disease Control (CDC) guidelines, a second pneumococcal immunization, Prevnar 23, should have been offered to the resident one year after the Prevnar 13 was administered. No documentation could be located in resident 17's medical record to indicate whether or not he had been offered the Prevnar 23. An immunization consent form dated 10/5/18 revealed resident 17 received an influenza vaccination. However, the form did not indicate whether or not the resident was offered the Prevnar 23 pneumococcal immunization. Progress notes for resident 17 from October and November 2018 did not indicate whether resident 17 had been offered the Prevnar 23. On 9/26/19 at 2:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that all immunizations provided to the residents were listed in the medical record, under the immunizations tab. The DON stated that she was unsure if resident 17 had received or declined his Prevnar 23 immunization, and would follow up. As of 10/1/19, no additional information had been provided.

c. Multiple residents were seated at the north west table when the meal was scheduled to start. i. At 12:14 PM, the first resident, resident 27, was served her lunch. ii. The last person served at the table was served at 12:25 PM. [Note: This was 11 minutes after the first person was served at this table.] d. Resident 19 was seated with a tablemate at the southwest table when the meal was scheduled to start. i. The tablemate was served at 12:07 PM. ii. Resident 19 was served at 12:18 PM. [Note: This was 11 minutes after resident 19's tablemate was served at this table.] 2. On 9/24/19 at 8:01 AM, an observation was made of the breakfast time meal in the main dining room. a. Residents 32, 5, and 27 were observed sitting at the north west table when the meal was scheduled to start. i. At 8:03 AM, resident 32 was served her breakfast. ii. At 8:06 AM, resident 27 was served her breakfast. iii. At 8:15 AM, resident 5 was served her breakfast. [Note: This was 12 minutes after the first person was served at this table.] b. Residents 19 and 14 were seated at the southwest table when the meal was scheduled to start. i. At 8:03 AM, resident 19 was served her breakfast. ii. At 8:15 AM, resident 14 was served his breakfast. [Note: This was 12 minutes after the first person was served at this table.] 3. On 9/25/19 at 12:00 PM, an observation was made of the lunch time meal in the main dinning room. a. Multiple residents were seated at the north east table when the meal was scheduled to start. i. At 12:04 PM, the first resident was served lunch. ii. The last person at the table was served at 12:18 PM. [Note: This was 14 minutes after the first person was served at this table.] 4. During each of the above listed meal observations, some residents were provided glass goblets, and other residents were served in paper cups with a straw and lid. On 9/24/19 at 2:30 PM, an interview was conducted with multiple residents as part of a resident council meeting. a. The residents were asked why some people were served their beverages in paper cups. One of the residents stated that some residents had to use paper cups because they spill. b. During the resident council, resident 11 stated that he was usually the first one in the dining room in the morning at approximately 7:40 to 7:45 AM. Resident 11 stated that he did not typically get served his meal until 8:30 or 8:45 AM, and was upset that he was consistently waiting an hour to be served. On 9/26/19 at 1:49 PM, an interview was conducted with the Dietary Manager (DM). The DM stated residents were served according to when residents' orders were taken by the Certified Nursing Assistants (CNA)s. The DM stated that there had been resident complaints in the past regarding residents not being served at the same time. The DM stated that if a CNA did not get all the residents' orders at the same time then residents were not served at the same time. The DM stated that the CNAs gave the orders to the kitchen, then the kitchen served the meals in the order they were provided from the CNAs. The DM stated if the residents were all at the table their orders were to be taken at the same time and they should be served at the same time. The DM stated that the paper cups were used for resident that needed straws, or who had a history of spilling their drinks. The DM stated that the paper cups were lighter weight than the glass ones. The DM stated that there were no other cups except glass or paper to serve the residents. Based on observation and interview it was determined for 7 of 32 sample residents, that the facility did not treat each resident with dignity and respect. Specifically, residents at the same table were not served at the same time and some residents were served beverages in paper cups. Resident identifiers: 5, 11, 14, 19, 27, 32 and 34. Findings include: 1. On 9/23/19 at 12:00 PM, an observation was made of the lunch meal in the dining room. The following was observed: a. Four residents, including resident 34 was observed sitting at the same table. i. The first resident was observed to be served lunch at 12:17 PM. ii. Resident 34 was observed to be served the lunch meal at 12:26 PM, and was the last one served at the table. [Note: Resident 34 waited 21 minutes after the first resident was served. All the residents were observed to be seated at the table together at 12:00 PM.] b. On 9/23/19 at 12:20 PM, an observation was made of resident 11. Resident 11 stated to a tablemate We come early and have to wait. Resident 11 further stated that he came in late and sometimes was served quickly. Resident 11 stated that usually he had to wait an hour to be served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 245 was admitted to the facility on [DATE] with diagnoses that included left rib fracture, repeated falls, hypertension, aortic valve stenosis, heart failure, atrial fibrillation, emphysema, hypothyroidism, hyperlipidemia, personal history of transient ischemic attack (TIA) and cerebral infarct without residual deficits, dependence on supplemental oxygen, long term (current) use of anticoagulants, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia with lower urinary tract symptoms, unspecified vitamin deficiency, unspecified pain and constipation. On 9/24/19, resident 245's medical record was reviewed. On 9/20/19, resident 245 had a creatinine kinase (CK) level ordered and drawn STAT (immediately) at 3:15 PM. Laboratory results revealed CK to be lower than reference ranges listed on the laboratory sheet. Results were faxed from a local hospital to the facility at 4:20 PM. A physician's order dated 9/20/19 revealed, Draw CK level STAT for decreased liver fx (function) A laboratory result form dated 9/20/19 revealed the CK was completed STAT and faxed to the facility at 4:20 PM. Progress notes for resident 245 revealed the following: a. On 9/20/19 at 3:26 PM, received call from [name of physician] concerning res (resident) liver fx. [name of physician] nurse [name of nurse] gave orders to D/c (discontinue) tylenol et (and) draw a CK level STAT. CK drawn at 1515 (3:15 PM) from R (right) forearm, sent with transportation to lab, waiting for results. b. On 9/21/19 at 3:20 PM, Received the following lab result from [name of local hospital] Lab. Creatinine Kinase- 23 Lab results faxed to [name of physician]. c. On 9/23/19 at 4:18 PM, Called MD (medical doctor) office to follow up on CK done. MA (medical assistant) stated they had lab results MD has not reviewed them yet will call us if any orders change. d. On 9/24/19 at 2:28 PM, Called PCP (primary care physician) to f/u (follow up) on labs from 9-20, no response, left message with call back info. e. On 9/26/19 at 2:36 PM, Called PCP to f/u on lab, was told lab is normal, no new orders. [Note: This was six days after the lab was drawn STAT.] On 9/26/19 at 2:43 PM, an interview was conducted with DON. The DON stated she did not know why there was a delay in the physician reviewing the laboratory results for resident 245. Based on observation, interview, and record review, it was determined for 6 of 32 sample residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident was given a potassium wasting diuretic without a supplement or monitoring for effectiveness. Two residents had antibiotics ordered that were not started timely. Additionally, several residents had lab results that were not followed up on timely by the physician. Resident identifiers: 10, 31, 34, 95, 100, and 245. Findings include: 1. Resident 31 was admitted to the facility on [DATE], she was sent out to the hospital for a gastrointestinal bleed, and readmitted on [DATE] with diagnoses which included malignant ovarian cancer, gastrointestinal hemorrhage, sepsis due to Escherichia coli, urinary tract infection, aftercare following surgery for neoplasm, aftercare following surgery on the genitourinary system, speech and language deficits related to stroke, atrial fibrillation, severe malnutrition, hypotension, hyperlipidemia, gastro-esophageal reflux disease, hypothyroidism, and major depressive disorder. On 9/25/19 at 9:31 AM, an observation was made of resident 31's legs. Resident 31 was sitting in her wheelchair with her legs down, she did not have any compression wraps on her legs, and both of her legs had 3-4 plus pitting edema. Resident 31's medical record was reviewed on 9/25/19. A 'Skilled Charting' assessment dated [DATE] prior to her discharge to the hospital documented that resident 31 had no edema. A current 'Skilled Charting' assessment dated [DATE] documented that resident 31 had 3+. Deep pitting, indentation remains for a short time, leg looks swollen to both legs. A nurse's progress note dated 9/11/19 documented IDT (interdisciplinary team) held this AM (morning) with res (resident), husband, and daughter. PT (physical therapist) noted that there is a large increase of edema to BLE (bilateral lower extremities) and that res has been less active since readmitted . 2+ pitting edema to BLE. Noted almost 30 lb (pound) increase in wt (weight) from this admit to last weight almost a month ago. Resident 31's weights documented by the facility showed: a. On 8/8/19 resident 31 weighed 112 pounds b. On 8/23/19 resident 31 weighed 108.8 pounds c. On 9/7/19 resident 31 weighed 137 pounds d. On 9/13/19 resident 31 weighed 131.4 pounds e. On 9/20/19 resident 31 weighed 132.4 pounds [Note: Resident 31 had a 29 pound weight gain upon readmission from the hospital.] In addition to weight gain and increased edema, a review of resident 31's vital signs revealed that resident 31's room air oxygen saturations were decreased upon readmission and required that resident 31 be on 1-3 liters of oxygen via nasal cannula. A follow up 'Weight Change Note' was also entered on 9/11/19 and documented Discussed in nutrition risk committee meeting with RD (registered dietitian), ADON (Assistant Director of Nursing), and DM (dietary manager) attending. Resident recently had a brief hospitalization and was re-admitted to the facility with a questionable weight of 137# (pounds) which is up significantly from the weight prior to discharge to the hospital of 108.8#. A re-weight is pending att (at this time). Nursing reports that resident received IVFs (intravenous fluids) due to GI (gastrointestinal) bleed. Will ctm (continue to monitor). A nurse's note sated 9/12/19 documented This nurse called [MD (medical doctor) 1]'s office to discuss the concerns brought up in IDT regarding this residents. 2+ swelling BLE and a 30 pound weight gain over the past month. The nurse for [MD 1]'s office didn't seem to concernedet (sic) stated that [resident 31] has a dr. appointment tomorrow and these concerns could be discussed then. A nurse's note from resident 31's follow up with MD 1 on 9/13/19 stated Orders received after appt (appointment) with [MD 1]: Lasix 20 mg (milligrams) PO (by mouth) QD (every day). On 9/14/19 a physician's order was entered for Lasix Tablet 20 MG (Furosemide) Give 20 mg by mouth one time a day for diuretic. According to the Wolters-Kluwer 2016 Nursing Drug Handbook; pages 655-658; considerations when giving furosemide, which is a potassium wasting diuretic, Black Box Warning: Drug is a potent diuretic and can cause severe diuresis with water and electrolyte depletion.Watch for signs of hypokalemia. Consult prescriber and dietician about high potassium diet or potassium supplements. [Note: hypokalemia is a condition of potassium deficiency. No orders for a high potassium diet or potassium supplement were started.] A review of resident 31's lab results revealed that her potassium level on 8/15/19 was 3.3 mmol/L (millimole/liter), and on 8/19/19 her potassium level was 3.4 mmol/L. Normal potassium level range is 3.5-5.0 mmol/L. Resident 31's potassium level had not been monitored since her readmission to the facility and the new order for Lasix was started. According to Laboratory and Diagnostic Tests with Nursing Implications Eight Edition, considerations for decreased potassium levels include: . Observe for signs and symptoms of hypokalemia, such as vertigo (dizziness), hypotension, cardiac dysrhythmias, nausea, vomiting, diarrhea, abdominal distention, decreased peristalsis, muscle weakness, and leg cramps.Monitor serum potassium level in clients receiving potassium-wasting diuretics. On 9/25/19 at 2:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MD believed resident 31 had low protein levels that were contributing to her edema, and stated that the facility was not monitoring resident 31's albumin/protein levels. The DON stated that the MD ordered Boost to increase resident 31's protein. [Note: a progress note dated 9/19/19 stated that Boost was ordered by the registered dietitian related to marginal oral intake.] The DON stated that when Lasix was administered the facility would monitor a resident's weight to determine how much fluid output the resident had. The DON was unable to answer whether she would be concerned about the minimal amount of weight loss resident 31 had had while on Lasix. The DON stated that the nurse management monitored for effectiveness during 'Weight Meeting' every Monday. The DON stated that she believed the pharmacist asked for labs to be done every 3 months when the pharmacy review was conducted. The DON stated that potassium supplements were given with potassium wasting diuretic only when the physician ordered them. The DON stated that she was not aware that resident 31 had a low potassium level prior to starting Lasix, stated that she did not know if resident 31's potassium was being monitored. The DON stated that the facility was also treating resident 31's edema by elevating her legs and encouraging resident 31 to lie down. The DON stated that those interventions were communicated to the floor staff through the 'communication book' at the nurses' station. On 9/25/19 at 3:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that resident 31 did not have any interventions listed in the 'communication book' to elevate legs, encourage to lie down, or other interventions to help with edema. CNA 4 stated that the CNA's did not do any interventions to help with resident 31's edema, stated that the nurses treated resident 31's edema. On 9/26/19 at 8:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that when a resident was on a diuretic staff should monitor for edema, urine output, blood pressure, heart rate, and lungs sounds. LPN 3 also stated that since Lasix was a potassium wasting diuretic it should be given with a potassium supplement and the facility should also monitor potassium levels. On 9/26/19 at 9:48 AM, a follow up interview was conducted with the DON. The DON stated that she talked with the doctor about resident 31's edema and lasix, stated that the MD ordered and BMP (basic metabolic panel) and BNP (brain natriuretic peptide) labs as well as stopped resident 31's cardiac medication. 2. Resident 10 was admitted on [DATE] with diagnoses which included weakness, hip fracture, pelvic fractures, hyperlipidemia, major depressive disorder, vitamin deficiency, hypertension, constipation, and pain. Resident 10's medical record was reviewed on 9/25/19. A nurse's progress note dated 9/10/19 at 2:06 PM documented PCP (primary care physician) contacted about S/S (signs and symptoms) of UTI, cloudy urine with mucus noted et (and) changes in LOC (level of consciousness), order received to obtain UA (urine analysis) with C&S (culture and sensitivity), no other needs or concerns at this time. A nurse's progress note dated 9/10/19 at 5:05 PM documented UA obtained by CC (clean catch) at 1650 (4:50 PM ) per MD orders, sample labeled et sent to [hospital name] lab (laboratory), no other needs or concerns at this time. Laboratory results from the hospital documented that the results were completed and faxed back to the facility on 9/10/19 at 6:58 PM. The results indicated that the resident had a UTI based on the following values: a. WBC (white blood cells) >30 Normal range: [0-5] b. RBC (red blood cells) 11Normal range: [0-2] c. Bacteria 4+ Normal range: [None] The laboratory results from the hospital also documented that the culture results were faxed to the facility on 9/11/19 at 1:14 PM. [Note: The culture showed which bacteria organism caused the infection, but the results for the antibiotic sensitivity tests were still pending at that time.] A nurse's progress note dated 9/11/19 at 1:50 PM documented Called PCP office to verify they received UA results, MD out of office today. [Note: This attempt to notify of the MD of the UA results was almost 19 hours after initial results were received that indicated resident 10 had a UTI.] There was no MD response documented until 9/12/19 at 9:50 AM via a nurse's progress note res has UTI, still waiting for culture results. [MD 2] gave orders for pyridium PO 200 mg 2 tablets 3 times a day as needed for symptoms associated with a UTI. [Note: This was 38 hours after initial results were received that indicated resident 10 had a UTI, and 20 hours after staff had attempted to contact the MD with the UA results.] A nurse's progress note dated 9/12/19 at 1:42 PM documented Received call from [MD 2]'s office. They have reviewed the C & S from the urine sample and have ordered cipro 250 mg tab BID (twice a day) for 7 days due to UTI. A physician's order for Cipro 250 mg twice a day for 7 days was then entered to start on 9/12/19 at 9:00 PM. [Note: The order was entered to start over 7 hours after the physician gave the order.] On 9/26/19 at 11:43 AM, an interview was conducted with the DON. The DON stated that all lab results should be reported to the MD the same day they were received, and that if the MD did not respond within 4 hours then the on call MD should be called. The DON stated that she would be very concerned with UTI results not being reported until the next day. The DON further stated that all orders for antibiotics should have the first dose administered within 4 hours of receiving the order from the MD. 3. Resident 34 was admitted to the facility on [DATE] with diagnoses that included femur fracture, osteoporosis, and hypertension. On 9/23/19, resident 34's medical record was reviewed. On 9/16/19, resident 34 had a basic metabolic panel, Vitamin B-12 level, serum iron, Vitamin D level, and complete blood count (CBC) drawn. The lab results indicated that resident 34's Vitamin B-12, Vitamin D, hematocrit and hemoglobin were lower than the reference ranges listed on the laboratory sheet. Progress notes for resident 34 revealed the following: a.On 9/18/19, Called PCP (primary care physician) to verify they received faxed results of most recent labs, included call back and fax number for new orders. Called this afternoon to f/u (follow up), but MD is out of office today. b. On 9/23/19, Called PCP to verify results from recent labs. MA (medical assistant) stated PCP has labs but no orders at this time. c. On 9/24/19, Called PCP to f/u on lab results, was told MD has not yet reviewed them but they would put an alert to have MD check soon. Gave call back number. d. On 9/25/19, Medical director contacted to review labs drawn. Physician stated trends looking good at this time no changes needed . [Note: This was nine days after the labs were drawn.] On 9/25/19 at 9:25 AM, an interview was conducted with the DON. The DON stated she was the one who entered the 9/23/19 progress note for resident 34. The DON stated when she attempted to contact the physician on 9/23/19, she was told by the MA that the physician had not yet reviewed the results. The DON stated that she was not sure why there was a delay in the physician reviewing the labs. 4. Resident 100 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, respiratory failure, and atrial fibrillation. On 9/23/19 resident 100's medical record was reviewed. Progress notes for resident 100 revealed the following: a. On 9/13/19 Received call back from [name of physician] office with TO (telephone order): PCP will manage coumadin et labs. Increase coumadin to 4 mg QD (every day), recheck PT/INR in 1 wk (9-20-19). b. On 9/21/19 at 3:19 PM, Received lab results for PT/INR (Prothrombin time/International Normalized Ratio) - 14.4, 1.1. Labs faxed to [name of physician]'s office. Will contact MD during hrs (hours) to get orders. c. On 9/23/19, Called MD office to report PT/INR drawn over weekend. MA stated MD had results has not reviewed them yet will call us with orders. d. On 9/24/19, Called PCP about coordinating PT/INR draws and dialysis. Received TO: PT/INR on Thursday (9-26-19) to be drawn at Dialysis. [Note: This was 3 days after the PT/INR was drawn.] On 9/25/19 at 10:00 AM, an interview was conducted with the DON. The DON acknowledged that there was a three day delay in the physician responding to the PT/INR results. The DON stated that as of 9/24/19, the facility had referred the resident to another physician for coumadin monitoring. 5. Resident 95 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare, hypertension, Crohn's disease, anxiety, hereditary deficiency of other clotting factors, and major depressive disorder. On 9/24/19 at 10:00 AM, an interview was conducted with resident 95. Resident 95 stated that she did not think facility staff were communicating well with each other or the physicians. Resident 95 stated that she told facility staff on 9/20/19 that she felt like she had thrush. Resident 95 stated that a nurse came in and looked at her mouth and throat and stated oh yes, you do have thrush. Resident 95 stated she was not sure if she had received the medication for her thrush yet. On 9/23/19, resident 95's medical record was reviewed. Progress notes for 9/20/19 through 9/23/19 did not reveal any information regarding resident 95's thrush symptoms or communication with the physician, until 9/23/19. On 9/23/19 at 6:31 PM, facility staff entered a progress note that stated, Diflucan 100mg (milligrams) PO (by mouth) daily x (for) 3 days for thrush. Review of resident 95's September 2019 Medication Administration Record (MAR) was reviewed. The MAR indicated that resident 95 received her first dose of Diflucan on 9/23/19 at 9:00 PM. On 9/26/19 at 10:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he had worked on 9/21/19 and was assigned to care for resident 95 that day. LPN 1 stated that he had spoken with resident 95 regarding her symptoms of thrush on 9/21/19. LPN 1 stated that he and 2 students had looked at resident 95's throat and assessed her as having symptoms consistent with thrush. LPN 1 stated that he thought we got the order for a medication to treat resident 95's thrush. LPN 1 stated that he told the charge nurse about it and he thought that the charge nurse entered the physician's order, but maybe the charge nurse thought LPN 1 was going to enter it. LPN 1 stated that the medication the physician prescribed was Diflucan and it arrived the night of 9/21/19. LPN 1 stated he was not sure why resident 95 was not administered the Diflucan before 9/23/19. On 9/26/19 at 11:30 AM, an interview was conducted with the DON regarding the delay in treating resident 95's thrush. The DON stated that the resident had brought that to her attention earlier that day and staff would be addressing her concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 2 of 32 sample residents that the facility did not ensure that it was free from medication error rate of 5% or greater. Specifically, observations of twenty six medication opportunities, on 9/26/19, revealed five medication errors which resulted in a 19.23% medication error rate. Resident identifiers: 27 and 197. Findings include: 1. Resident 27 was admitted on [DATE] with diagnoses which included weakness, pain, hypertension, hyperlipidemia, gastro-esophageal reflux disease without esophagitis, constipation, stress incontinence, presence of cardiac pacemaker, insomnia, atrial fibrillation, vitamin deficiency, angina, seasonal allergic rhinitis, osteoporosis, dysphagia, polyosteoarthritis, amnesia, macular degeneration, pneumonia, and major depressive disorder. On 9/26/19 at 7:33 AM, an observation was made of Licensed Practical Nurse (LPN) 2 during morning medication administration. LPN 2 was observed to administer 14 medications to resident 27, among those medications were Aspirin EC (enteric coated) 81 mg (milligrams), Metoprolol Succinate ER (extended release) 25 mg, Propafenone ER 225 mg, and Calcium/Vitamin-D 600mg/300units. After placing all of resident 27's pills into a medication cup, LPN 2 was observed to crush them all and mix them with applesauce before administering them to the resident. According to Wolters-Kluwer 2016 Nursing Drug Handbook: a. Aspirin EC on page 161 Give enteric-coated forms whole; don't crush or break these tablets. b. Metoprolol Succinate ER on page 940 Extended-release tablets may be cut in half on scored line, but never crushed or chewed. c. Propafenone ER on page 1203 Don't crush or open the extended-release capsules. Resident 27's medical record was reviewed for the reconciliation of the medications on 9/26/19. According to Physician orders, resident 27 was to receive Calcium/Vitamin-D 600mg/400units twice a day for vitamin deficiency. On 9/26/19 at 9:00 AM, resident 27's September Medication Administration Record (MAR) was reviewed. It was discovered that no medications we documented as administered to resident 27. On 9/26/19 at 9:02 AM, and interview was conducted with LPN 2. LPN 2 stated that he did not like to chart on the facility ipads that were used on the nurse medication carts, and stated he preferred to chart on the computer at the nurses' station. LPN 2 stated that he charted all of the medications he administered once he was done passing morning medications to all of his residents. LPN 2 verified that Extended-Release and Enteric-Coated medications were not supposed to be crushed. LPN 2 stated that resident 27 had difficulty swallowing, therefore he crushed her medications. LPN 2 stated that he was sure there were other options for resident 27 to get non Extended-Release or Enteric-Coated medications, but LPN 2 did not know if any had been attempted. LPN 2 stated that the risk of crushing those medications were that the resident would receive a large dose immediately and no medication later in the day. LPN 2 also compared the Calcium/Vitamin-D and verified that resident 27 was administered the incorrect dose. On 9/26/19 at approximately 9:30, an interview was conducted with the Director of Nursing (DON). The DON stated that Extended Release and Enteric Coated medications should never be crushed. The DON also stated that all medications should be documented immediately after administration to the resident. 2. Resident 197 was admitted on [DATE] with diagnoses which included joint replacement surgery, hypertension, rheumatoid arthritis, osteoporosis, macular degeneration, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, anxiety disorder, asthma, vitamin B deficiency, presence of cardiac pacemaker, presence of left artificial knee joint, chronic use of steroids, and major depressive disorder. On 9/26/19 at 7:45 AM, an observation was made of LPN 3 during morning medication administration. LPN 3 was observed to administer eleven medications to resident 197, among those medications was Biotin 500 mcg (micrograms). Resident 197's medical record was reviewed for reconciliation of the medications on 9/26/19. According to Physician orders, resident 197 was to receive Biotin 5000 Capsule (Biotin) Give 1 capsule by mouth one time a day for supplement. A nurses' note dated 9/13/19 stated Called PCP (primary care physician) to notify of admission to this facility and clarify new orders,. Clarification: Biotin 5000 mcg QD (every day). On 9/26/19 at 9:41 AM, an interview was conducted with LPN 3. LPN 3 verified that resident 197 received Biotin 500 mcg, when she was supposed to receive Biotin 5000 mcg every day.

4. On 9/24/19 at 9:43 AM, CNA 5 was observed delivering fluid-filled cups to resident rooms using a cart that contained a rack on the top shelf. The rack held multiple cups of liquid. Some cups had lids and straws; other cups had no lids but did have straws. The rack contained some empty cups that were placed upside down. Soiled cups were observed to be placed upside down, directly adjacent to clean liquid-filled cups with no lid. On 9/24/19 at 9:44 AM, an interview with CNA 5 revealed, When I remove them (previously used cups) from the room I place them upside down. I give the resident a new cup. I do not know why there are no lids on these cups. On 9/26/19 at 1:50 PM, an interview was conducted with the DM. The DM stated that all cups of fluid that are being transported to resident rooms should have lids on them. The DM stated, Clean and dirty cups should be in different racks. It would be easy to make that happen. The cart has two levels. 3. On 9/23/19 at 12:17 PM, an observation was made of the lunch time hall trays being served to the rooms down the Nature and Element halls. The tray of desserts and rolls were observed to be covered until the meal cart arrived on the hall. Certified Nursing Assistants (CNA)s were observed to uncover the dessert and roll trays to serve to the first resident, the trays were not covered back up as the cart was wheeled down the hall to serve to subsequent residents. On 9/26/19 at 1:50 PM, an interview was conducted with the DM. The DM stated that all food and drinks must be covered when being transported in the halls. 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, sanitizer buckets did not contain sanitizer, there was expired food in the refrigerator, items were soiled in the kitchen, food was uncovered when transported through the hall, and dirty water mugs were placed in the same basket as clean water mugs. Findings include: 1. On 9/23/19 at 9:32 AM, an initial tour of the kitchen was conducted. The following was observed: a. The plastic curtains into the refrigerator and freezer were soiled. b. The floor of the freezer was soiled with a black substance. There was a white substance around the bottom of the mixer. c. There were 8 yogurts with a use by date of 9/21/19 in the refrigerator in the bistro area. d. Dietary Aide (DA) 1 was observed to removed a rag from a red bin labeled sanitizer. DA 1 was observed to wipe the steam table, the shelf above the steam table, and the shelf under the steam table. DA 1 was observed to use a quaternary test strip to test the sanitizer solution. DA 1 was observed to place the strip into the sanitizer and the strip did not change color. DA 1 stated that the sanitizer buckets were made at 6:45 AM by DA 2. DA 1 stated that the sanitizer solutions did not have enough sanitizer. DA 1 was observed to check another sanitizer bucket that DA 2 was using. DA 2 was observed to wipe the food preparation area with the sanitizer from another bucket. DA 1 was observed to place the sanitizer test strip into the red sanitizer bucket. The test strip was observed to not change color. DA 1 was observed to go to the sanitizer dispenser. DA 1 was observed to pull out an empty bucket, indicating that no sanitizer was in the bucket. DA 1 stated that was why the test strips did not change color. DA 2 was interviewed. DA 2 stated that she filled the sanitizer buckets first thing. DA 2 stated that she filled the sanitizer buckets at 6:30 AM. DA 2 stated that she did not use test strips to test the sanitizer solution. DA 2 stated that she had never checked the sanitizer solution. 2. On 9/26/19 at 1:03 PM, a follow up tour of the kitchen was conducted. The following was observed: a. The plastic curtains into the refrigerator and freezer were soiled. b. There was duct tape on the ice cream machine in the bistro. c. There were 8 yogurts with a use by date of 9/21/19 in the refrigerator in the bistro area. d. There was a plastic cup labeled Thickener Spoon that was duct taped to the counter in the bistro. On 9/26/19 at 1:49 PM, the Dietary Manager (DM) was interviewed. The DM stated that the refrigerator curtains were cleaned weekly. The DM stated that the freezer curtains were cleaned less often than the refrigerator ones. The DM stated that Certified Nursing Assistants (CNA) cleaned out the bistro area. The DM stated that the kitchen staff checked the refrigerator and made sure items were stocked and the refrigerators were clean. The DM did not have any information regarding the duct tape.

2. On 9/23/19 at 12:17 PM, an observation was made of the lunch time hall trays being served to the rooms down the Nature and Element halls. CNA 1 was observed to deliver and set up trays in several resident rooms without using hand sanitizer in between. 3. On 9/25/19 at 12:51 PM, an observation was made of the lunch time hall trays being served to the rooms down the Floral halls. The CNA was observed to deliver and set up trays in 6 resident rooms without using hand sanitizer in between. On 9/26/19 at 2:36 PM, an interview was conducted with the DON. The DON stated that the CNA's should be using hand sanitizer when leaving a resident room, and stated that if the CNA's hands were visibly soiled the CNA should then wash with soap and water. The DON verified that CNA's should use hand sanitizer in between delivery and set up of trays in resident rooms. Based on interview and observation, 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, cross-contamination was observed during mealtimes. Resident identifiers: 19 and 22. Findings include: 1. On 9/23/19, an observation was made of the lunch meal in the main dining room. The following observations were made: a. Resident 19 was served her meal at 12:18 PM. b. At 12:19 PM, Certified Nursing Assistant (CNA) 6 was observed to assist resident 19 with multiple bites of food, by picking up the resident's fork and feeding the resident. Resident 19 then took the fork into her own hands and began attempting to feed herself. CNA 6 then moved around the table and assisted a second resident with eating, by picking up the resident's fork and feeding the resident until 12:22 PM. At 12:22 PM, resident 22 arrived and sat between resident 19 and the second resident. At this point CNA 6 changed tasks, and the second resident was observed to use her fork to attempt to feed herself. c. At 12:25 PM, CNA 6 then returned to resident 19. CNA 6 fed resident 19 multiple bites of food by scooping the food onto a fork and placing the forkful of food into resident 19's mouth. CNA 6 then returned to the second resident. d. At 12:28 PM, CNA 6 again returned to assist resident 19, and assisted for approximately 2 minutes. e. At 12:47 PM, CNA 6 then began assisting resident 22 with her meal. At no time during the observation was CNA 6 observed to wash and/or sanitize her hands between touching resident utensils that the residents were also using. On 9/26/19 an interview was conducted with the facility Director of Nursing (DON). The DON stated that her expectation was that staff would sanitize their hands between assisting residents who were also using their utensils in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 1 was admitted to the facility on [DATE] with diagnoses that include weakness, displaced fracture of base of neck of right femur, morbid (severe) obesity due to excess calories, unspecified gout, unspecified site osteoarthritis, essential (primary) hypertension, unspecified hypothyroidism, recurrent and mild major depressive disorder, unspecified heart failure, Parkinson's disease, unspecified vitamin deficiency, unspecified rheumatoid arthritis and pain. On 9/26/19, resident 1's medical record was reviewed. A laboratory result form dated 4/17/18 revealed urine was collected on 4/17/18 and a urinalysis was performed. Macroscopic urinalysis revealed Leukocyte Esterase to be moderately present. Microscopic urinalysis revealed an elevated WBC (white blood cell) count, elevated RBC (red blood cell) count, elevated epithelial cell count and a 4 plus bacteria count. A laboratory result form dated 4/20/18 revealed urine was sent for bacterial sensitivity to antibiotic therapy. Results identified susceptibility to the following antibiotics: Gentamicin, Imipenem, Levofloxacin, Meropenem, Nitrofurantoin, Pipercillin/Taxobactam, Tobramycin and Trimethoprim/Sulfamethoxazole. A physician's order dated 5/16/18 revealed, Macrobid Capsule 100mg (Nitrofurantoin Monohyd Macro) Give 100 mg by mouth one time a day for prophylactic for UTI (urinary tract infection). Review of resident 1's Medication Administration Records (MARs) revealed that resident 1 was administered Macrobid Capsule 100mg (Nitrofurantoin Monohyd Macro) by mouth each day at 9:00 AM from October 1, 2018 through September 26, 2019. According to [NAME] CE, et al, in their article The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents, published in the Journal of the American Geriatrics Society (JAGS) August, 2017, Non-specific signs/symptoms appeared to influence prescribing more often than tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide their decision-making process to reduce antibiotic overuse and antibiotic resistance. According to [NAME] T, et al, in their article Measuring Antibiotic Appropriateness for Urinary Tract Infections in Nursing Home Residents, published in Infection Control & Hospital Epidemiology (ICHE) Journal, August, 2017, as abstracted in PubMed, We assessed the appropriateness of initiating antibiotics in 49 nursing home (NH) residents receiving antibiotics for urinary tract infection (UTI) using 3 published algorithms. Overall, 16 residents (32%) received prophylaxis, and among the 33 receiving treatment percentage of appropriate use ranged from 15% to 45%. Opportunities exist for improving UTI antibiotic prescribing in NH. Based on interview and record review it was determined for 3 of 32 sample residents that the facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility administered prophylactic antibiotics without medical rationale. Resident identifiers: 1, 10, and 21. Findings included: 1. Resident 10 was admitted on [DATE] with diagnoses which included weakness, hip fracture, pelvic fractures, hyperlipidemia, major depressive disorder, vitamin deficiency, hypertension, constipation, and pain. Resident 10's medical record was reviewed on 9/25/19. A physician's order was started on 9/12/19 for Ciprofloxacin 250 mg (milligrams) by mouth twice a day for 7 days for UTI (urinary tract infection). A nurses' note dated 9/13/19 documented Family asked for prophylactic anbx (antibiotics) for UTI's, floor nurse called et (and) notified MD (medical doctor), MD office called back with TO (telephone order): Start Prophylactic Antibiotic after completes current anbx course, Give 250 mg by mouth at bedtime for UTI prevention starting 9-19-19. A physician's order was started on 9/19/19 for Ciprofloxacin 250 mg by mouth at bedtime for UTI prevention. According to Wolters-Kluwer 2016 Nursing Drug Handbook of Ciprofloxacin; pages 331-335; Long-term therapy may result in over-growth of organisms resistant to drug. On 9/26/19 at 11:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that prophylactic antibiotics should not be the first line of defense, and stated that cranberry supplements or peri-care education should be attempted first. The DON stated that if the family wanted prophylactic antibiotics, it was the responsibility of facility staff to educate the family about the risks of long term antibiotic use. The DON stated that one of those risks would include drug resistance and growth of super bugs, and stated long term use was not good for you. [Note: an order for Cranberry supplement was started on 9/18/19, which was the day before the prophylactic antibiotic was started.] 3. Resident 21 was admitted to the facility on [DATE] with diagnoses that included spastic hemiplegia, major depressive disorder, weakness, and pain. On 9/25/19, resident 21's medical record was reviewed. A physician's order dated 1/6/19 revealed that resident 21 was prescribed Keflex 250 mg two times daily for prophylactic abx (antibiotics) for UTI . A physician's order dated 6/10/19 increased resident 21's Keflex dose to 500 mg two times daily for a figner infection. A physician's order dated 7/17/19 decreased resident 21's Keflex dose to 500 mg one time daily for prophylactic abx therapy. A review of resident 21's medical record did not reveal that the physician had prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms.