Based on interviews, record review, and facility policy review, the facility failed to notify the physician after a resident sustained a fall for 1 (Resident #16) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Change in a Residents Condition or Status, revised in May 2024, revealed, Policy Statement Our facility promptly notifies the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(n): a. accident or incident involving the resident. An admission Record revealed the facility originally admitted Resident #16 on 08/11/2022, with diagnoses to include abnormal posture, hypertension, and personal history of traumatic brain injury. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. Resident #16's care plan, initiated on 08/13/2022 and cancelled on 03/22/2024, revealed the resident was at high risk for falls per the standardized fall scale, gait/balance problems, paralysis, and being unaware of their safety needs. Resident #16's incident report dated 11/23/2023, revealed the resident was found lying on the floor near their bed. According to the incident report, the resident stated they attempted to transfer themselves from the bed and fell to the floor. Per the incident report, there were no agencies or people notified of the resident's fall. Resident #16's incident report dated 01/07/2024, revealed the resident was found lying on the floor in front of their bed. According to the incident report, the resident stated as they reached for their wheelchair, they lost their balance and fell onto the buttocks. Per the incident report, the Administrator and Director of Nursing (DON) were notified of the resident's fall. During an interview on 05/13/2024 at 11:29 PM, Resident #16 stated they had fallen twice recently. During an interview on 05/16/2024 at 5:34 PM, the interim Medical Director stated she expected to be notified of every fall a resident had. During an interview on 05/17/2024 at 11:05 AM, the DON stated the physician should be notified of the resident's falls. During a follow-up interview on 05/17/2024 at 11:34 AM, the DON stated she did not find evidence to indicate the physician was notified of Resident #16's fall that occurred on 11/23/2023 and 01/07/2024. During an interview on 05/17/2024 at 4:28 AM, Registered Nurse #3 stated when a resident had a fall, the staff were expected to notify the DON, Administrator, the resident's emergency contact, and the physician. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she expected staff to notify her, the DON, and the physician when a resident fell.

2. An admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 was unable to complete the Brief Interview for Mental Status. The MDS revealed in the last seven days of the assessment period, the resident did not have an active diagnosis of seizures of insomnia. Resident #11's Order Summary Report, revealed an order dated 05/13/2024, for trazodone hydrogen chloride (an antidepressant medication) oral tablet, give 50 milligrams by mouth every 24 hours as needed for insomnia for 14 days. Resident #11's medical record did not reveal evidence to indicate the resident had a diagnosis of insomnia. During an interview on 05/17/2024 at 1:22 PM, the MDS Coordinator stated Resident #11 did not have a diagnosis in their medical record for all the medications the resident was prescribed. The MDS Coordinator stated obviously something got missed. According to the MDS Coordinator, she would contact the physician to get a diagnosis or have the physician's orders changed. During an interview on 05/18/2024 at 9:50 AM, the Director of Nursing (DON) stated the facility tried to eliminate errors in physician's orders and made it where only she and the MDS Coordinator implemented a resident's physician orders into the resident's medical record. The DON stated she could not explain how medications were ordered for Resident #11 when the resident did not have an appropriate diagnosis for the medication. During an interview on 05/18/2024 at 12:22 PM, the Administrator stated she expected the staff to follow the policy. Based on interviews, record reviews, and facility policy review, the facility failed to ensure an appropriate diagnosis was obtained for all psychotropic medications ordered for 2 (Resident #7 and Resident #11) of 5 sampled residents reviewed for unnecessary medication, psychotropic medications, and medication regimen review. Findings included: A facility policy titled, Psychotropic Medication Use, dated July 2022, revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 1. An admission Record revealed the facility admitted Resident #7 on 04/01/2024, with diagnoses of chronic respiratory failure with hypoxia, type 2 diabetes mellitus, protein-calorie malnutrition, unsteadiness on feet, encephalopathy, pneumonia, end stage renal disease, arteriovenous fistula, bipolar disorder, and dependence on renal dialysis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed in the last seven days of the assessment period, the resident did not have an active diagnosis of seizures of insomnia. Resident #7's Order Summary Report, with active orders as of 05/13/2024, revealed an order dated 04/01/2024, for divalproex sodium (a medication used to treat seizure disorders, certain psychiatric conditions, and to prevent migraine headaches) oral tablet delayed release, give 500 milligrams (mg) by mouth two times a day for seizures and an order dated 04/11/2024, for trazodone hydrogen chloride (an antidepressant medication) oral tablet, give 50 mg by mouth at bedtime for insomnia. Resident #7's medical record did not reveal evidence to indicate the resident had a diagnosis of seizures or insomnia. During an interview on 05/17/2024 at 1:22 PM, the MDS Coordinator stated Resident #7 did not have a diagnosis in their medical record for all the medications the resident was prescribed. The MDS Coordinator stated obviously something got missed. According to the MDS Coordinator, she would contact the physician to get a diagnosis or have the physician's orders changed. During an interview on 05/18/2024 at 9:50 AM, the Director of Nursing (DON) stated the facility tried to eliminate errors in physician's orders and made it where only she and the MDS Coordinator implemented a resident's physician orders into the resident's medical record. The DON stated she could not explain how medications were ordered for Resident #7 when the resident did not have an appropriate diagnosis for the medication. During an interview on 05/18/2024 at 12:22 PM, the Administrator stated she expected the staff to follow the policy.

3. An admission Record revealed the facility readmitted Resident #16 on 03/22/2024, with diagnoses to include disruption of wound, abnormal posture, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. Resident #16's care plan, initiated on 08/13/2022 and cancelled on 03/22/2024, revealed the resident was at high risk for falls per the standardized fall scale, gait/balance problems, paralysis, and being unaware of their safety needs. Resident #16's CAA [care area assessment] Worksheet, signed by the MDS Coordinator and dated 04/15/2024, revealed falls/functional status of the resident would be addressed in the resident's care plan. Resident #16's comprehensive care plan, with an admission date of 03/22/2024, revealed no current care plan with goals or interventions that addressed the resident's falls/functional status. During an interview on 05/17/2024 at 9:01 AM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for residents' care plan. Per the DON, care plans should be developed and/or updated on admission, quarterly, and when there was a significant change in a resident's status. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she deferred care plan questions to the DON and MDS Coordinator as she did not know what all was obligated to be placed in a resident's care plan. During an interview on 05/18/2024 at 1:04 PM, the MDS Coordinator stated she was responsible for the completion of a resident's comprehensive care plan. The MDS Coordinator acknowledged Resident #16 should have had a care plan that addressed falls upon readmission to the facility. 4. An admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. Resident #11's care plan, with an admission date of 04/16/2024, revealed no evidence of a care plan that addressed the resident's use of supplemental oxygen. On 05/13/2024 at 11:50 AM, Resident #11 was observed lying in bed with oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. On 05/18/2024 at 9:53 AM, Resident #11 was observed in the hall by the nurses' station. The resident had oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. During an interview on 05/14/2024 at 3:12 PM, the Director of Nursing (DON) stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 3:13 PM, the Administrator stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 4:03 PM, Licensed Practical Nurse #9 stated Resident #11 wore supplemental oxygen all the time. During a follow-up interview on 05/18/2024 at 12:09 PM, the Administrator stated she would expect a resident's use of supplemental oxygen to be addressed on the resident's care plan. During an interview on 05/18/2024 at 1:04 PM, the MDS Coordinator stated she was responsible for the completion of a resident's comprehensive care plan. Per the MDS Coordinator, Resident #11's use of supplemental oxygen should be care planned. 5. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed the facility admitted Resident #1 on 03/13/2024. Per the MDS, the resident had active diagnoses to include chronic obstructive pulmonary disease and asthma. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident used oxygen therapy. Resident #1's Order Recap Report, for the timeframe 03/01/2024 to 05/31/2024, revealed an order dated 03/27/2024, for continuous supplemental oxygen by way a nasal cannula at two to five liters per minute. Resident #1's comprehensive care plan did not reveal evidence to indicate the resident had a care plan that addressed their supplemental oxygen usage. On 05/13/2024 at 9:41 AM and 05/16/2024 at 1:21 PM, the surveyor observed Resident #1 with supplemental oxygen on. During an interview on 05/18/2024 at 1:04 PM, the MDS Coordinator stated she was responsible for the completion of a resident's comprehensive care plan. Per the MDS Coordinator, a resident's use of supplemental oxygen should be care planned. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she would expect a resident's use of supplemental oxygen to be addressed on the resident's care plan. Based on observations, interviews, record reviews, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 4 (Residents #1, #8, #11, #23) of 6 sampled residents reviewed for respiratory care and a care plan to address the fall status of 1 (Resident #16) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Care Plans, Comprehensive Person - Centered, revised in January 2024, revealed, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet resident's physical, psychological and functional needs is developed and implemented for each resident. The policy specified, 1. An admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. had intact cognition. The MDS revealed the resident used oxygen therapy. Resident #23's care plan, with an admission date of 04/05/2024, revealed no evidence of a care plan that addressed the resident's use of supplemental oxygen. On 05/13/2024 at 9:18 AM and 11:52 AM, the surveyor observed an oxygen tank/cylinder in Resident #23's room. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing (DON) stated Resident #23 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #23 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:29 PM, the MDS Coordinator stated Resident #23 did not have a care plan for their use of supplemental oxygen. During a follow-up interview on 05/17/2024 at 1:07 PM, the DON stated Resident #23 did not have a care plan to address their use of supplemental oxygen. 2. An admission Record revealed the facility admitted Resident #8 on 01/19/2024, with diagnoses to include acute respiratory failure with hypoxia, emphysema, pneumonia, and shortness of breath. An admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #8's care plan, with an admission date of 02/21/2024, revealed no evidence of a care plan that addressed the resident's use of supplemental oxygen. On 05/13/2024 at 9:29 AM and 05/14/2024 at 10:16 AM, the surveyor observed Resident #8 had supplemental oxygen on by way of a nasal canula and the oxygen concentrator was in the on position, set a three and a half liters per minute. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:43 PM, the MDS Coordinator stated Resident #8 did not have a care plan that addressed their supplemental oxygen usage.

Based on interviews, record reviews, and facility policy review, the facility failed to conduct neurological assessments following unwitnessed falls for 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Neurological Assessment, revised in October 2010, revealed, The purpose of this procedure is to provide guidelines for a neurological assement:1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. 1. An admission Record revealed the facility originally admitted Resident #16 on 08/11/2022, with diagnoses to include abnormal posture, hypertension, and personal history of traumatic brain injury. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident required substantial/maximal assistance with sit to stand, sit to lying, and chair/bed-to-chair transfers. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. Resident #16's care plan, initiated on 08/13/2022 and cancelled on 03/22/2024, revealed the resident was at high risk for falls per the standardized fall scale, gait/balance problems, paralysis, and being unaware of their safety needs. An incident report dated 11/23/2023 at 9:25 PM, revealed Resident #16 had an unwitnessed fall in their room. Per the incident report, the resident reported they attempted to transfer themselves to bed and fell to floor. The incident report, the resident denied they hit their head. An incident report dated 01/03/2024 at 3:15 PM, revealed Resident #16 had an unwitnessed fall in their room. Per the incident report, the resident stated they tried to transfer themself to their chair, when their leg became weak, so they sat on the floor. An incident report dated 01/07/2024 at 2:10 PM, revealed Resident #16 was found lying on the floor in front on their bed. Per the incident report, the resident reported as they reached for their wheelchair, they lost their balance and fell. An incident report dated 01/14/2024 at 7:32 PM, revealed a registered nurse (RN) entered Resident #16's room and found the resident on the floor. Per the incident report, the resident stated when they tried to transfer themselves, they stood up, lost their balance, and fell to the floor. Resident #16's medical record revealed no evidence to indicate the facility conducted neurological assessments after the resident had unwitnessed falls on 11/23/2023, 01/03/2024, 01/07/2024, and 01/14/2024. During an interview on 05/15/2024 at 9:27 AM, the Administrator stated neurological checks should be done immediately for all unwitnessed falls. During an interview on 05/15/2024 at 11:26 AM, the MDS Coordinator stated facility staff had been unable to locate the neurological assessment documentation for when Resident #16 had an unwitnessed fall on 01/032024. The MDS Coordinator stated a neurological assessment was not conducted when Resident #16 had witnessed falls on 01/07/2024 and 01/14/2024. Per the MDS Coordinator a neurological assessment should be conducted for 72 hours after a resident experienced an unwitnessed fall. During a telephone interview on 05/16/2024 at 5:08 PM, RN #5 stated a neurological assessment should be conducted for 72 hours after a resident had an unwitnessed fall. During an interview on 05/17/2024 at 11:05 AM, the Director of Nursing stated neurological checks should be completed for 72 hours after the resident sustained an unwitnessed fall. The DON acknowledged neurological checks were not done and they should have been. During an interview on 05/17/2024 at 4:28 AM, RN #3 stated neurological assessments should be conducted whenever a resident had an unwitnessed fall. 2. An admission Record revealed the facility originally admitted Resident #28 on 08/20/2023, with diagnoses to include abnormalities of gait and mobility, abnormal posture, fall on the same level, and polyneuropathy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required substantial/maximal assistance with sit to stand and chair/bed-to-chair transfers. Per the MDS, the resident had one fall in the last month, one fall in the last two to six months, and a fracture related to a fall in the last six months. Resident #28's care plan initiated on 02/01/2024, revealed the resident was at risk for falls per the standardized fall scale. An incident report dated 04/04/2024, revealed Resident #28 was found on the floor next to their bed. Per the incident report, the resident stated did not remember if they hit their head. Resident #28's medical record revealed no evidence to indicate the facility conducted neurological assessments after the resident had an unwitnessed fall on 04/04/2024. During an interview on 05/16/2024 at 12:33 PM, the Director of Nursing (DON) stated neurological checks were to be completed after an unwitnessed fall per the facility policy and were to be continued for three days post fall. The DON stated she was aware that currently, very few neurological checks were being completed after a resident had an unwitnessed fall. The DON stated she expected the staff to follow the policy and non-compliance could result in serious injury and/or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A facility policy titled, Fall and Fall Risk, Managing, revised in March 2018, revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. An admission Record revealed the facility readmitted Resident #16 on 03/22/2024, with diagnoses to include disruption of wound, abnormal posture, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. On 05/14/2024 on 11:54 AM, the surveyor observed a transfer pole (a floor to ceiling grab bar that provided support for sitting, standing, or transferring from one place to another) on the right side of the resident's bed. An incident report dated 03/24/2024 at 5:05 PM, revealed Resident #16 had an unwitnessed fall in their room that resulted in a bruise to the top of the head, bruising above and around the right eye, and a small hematoma around the right eyebrow. Per the incident report, the resident stated they lost their balance. Resident #16's Incident Audit Report, for the unwitnessed fall the resident sustained on 03/24/2024 at 5;05 PM, revealed the resident stated as they attempted to transfer themself to their bed, with the use of the transfer pole in their room, they lost their balance and fell. Per the Incident Audit Report, an intervention after the fall was to have the maintenance and therapy staff evaluate the transfer pole for appropriate placement and resident safety during transfers as the staff and the resident reported the transfer pole needed to be two to three inches closer to the resident's bed. During an interview on 05/15/2024 at 7:52 AM, the Administrator stated prior to Resident #16's readmission to the facility on [DATE], the transfer pole was reinstalled in the resident's rom. Per the Administrator, the best placement of the transfer pole was not evaluated. During an interview on 05/16/2024 at 1:58 PM, the Director of Rehabilitation (DOR) stated the maintenance staff ordered the transfer pole and he in Resident #16's room when the transfer pole was installed prior to the resident being readmitted to the facility. The DOR stated he was unable to provide documentation to indicate the facility determined Resident #16 was safe to use transfer pole. During a follow up interview on 05/18/2024 at 12:09 PM, the Administrator stated she expected for there to be an assessment of the resident before a transfer pole was installed in their room. The Administrator stated the transfer pole was a good intervention as it had worked in the past; however, it was a bad call to have the transfer pole installed before the resident was assessed to be able to use it when they readmitted to the facility in March 2024. Based on observations, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision was provided to maintain safety and prevent potential injury during smoke breaks for 1 (Resident #1) of 4 sampled residents reviewed for accidents. On 05/14/2024 at 11:57 AM, Resident #1 was smoking outside in the designated smoking area with a portable oxygen tank on the back of their wheelchair and, a nearby propane tank. The facility further failed to ensure 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents received adequate supervision and/or assistive devices to prevent falls. Findings included: 1. A facility policy titled, Smoking Policy - Residents, revised in August 2022 revealed, 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. Per the policy, 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. An admission Record revealed the facility initially admitted Resident #1 on 05/12/2023, with a medical history that included diagnoses of chronic obstructive pulmonary disease, moderate asthma, obstructive sleep apnea, and nicotine dependence, cigarettes. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident was a current tobacco user and used oxygen therapy. Resident #1's care plan, initiated on 03/13/2024 and revised on 05/03/2024, revealed the resident was a smoker. The goals of the care plan were the resident would not suffer an injury from unsafe smoking practices and would not smoke without supervision. Resident #1's Order Recap Report for the timeframe 03/01/2024 through 05/31/2024, revealed an order dated 03/27/2024, for continuous supplemental oxygen at two to five liters per nasal cannula. Resident #1's NSG [nursing]: Additional admission Assessments, dated 03/13/2024, revealed the resident smoked and there was a goal that specified the resident would not smoke without supervision. On 05/14/2024 at 11:57 AM, the surveyor observed a sign on a door in the dining room that led to the smoking area that specified, No Oxygen Beyond This Point. The surveyor noted Resident #1 was outside smoking and their oxygen tank was on the back of their wheelchair in the off position and the resident's nasal cannula rested on their left chest area. Resident #1 informed the surveyor that no staff went outside in the designated smoke area, so they could smoke. The surveyor noted another ashtray was about five to 10 feet from Resident #1 and that ashtray touched an outdoor grill that had an attached propane tank. During an interview on 05/14/2024 at 12:47 PM, the Administrator and Director of Nursing (DON) stated they were aware of the issue in the smoking area and they were changing their smoking policy immediately. Per the Administrator and the DON, the maintenance staff would lock the back door so that all residents who smoke would have to be let out by staff. They both stated oxygen tanks were normally taken off the back of the wheelchair and left in the resident's room. Per the Administrator and DON, they were not sure what happened and acknowledged staff did not have their eyes on Resident #1 and that was where the breakdown occurred. During an interview on 05/15/2024 at 1:07 PM, Certified Nursing Assistant (CNA) #11 stated when Resident #1 came for their cigarettes, she usually took the resident's oxygen tank off in the resident's room, but it was lunch time and busy and she overlooked it on 05/14/2024. During an interview on 05/14/2024 at 1:12 PM, Resident #1 stated once or twice they forgot to turn off their oxygen tank before they started to smoke a cigarette. Resident #1 stated no one had ever asked them to put their oxygen tank in a holder inside the facility prior to going outside to smoke. During an interview on 05/14/2024 at 2:39 PM, Registered Nurse (RN) #1 stated she completed Resident #1's smoking assessment when the resident admitted to the facility. RN #1 stated that, according to the assessment, a staff member should be outside supervising Resident #1 while the resident smoked. RN #1 stated that Resident #1's oxygen should be turned off and removed from the wheelchair prior to Resident #1 going outside to smoke, but since Resident #1 returned on 04/27/2024, staff did not ensure the resident's oxygen tank was removed during smoke breaks. During an interview on 05/14/2024 at 3:10 PM, Licensed Practical Nurse (LPN) #9 stated Resident #1's oxygen tank should not have been on the resident's wheelchair when the resident went outside to smoke as that is a huge safety risk. According to LPN #9, it had been Resident #1's practice to leave their oxygen tank on the back of the wheelchair and turn it off when they went outside to smoke; however, he was unsure if it was safe for the resident to do that on their own. 2. A facility policy titled Fall and Fall Risk, Managing, revised in March 2018, revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. An admission Record revealed the facility originally admitted Resident #28 on 08/20/2023, with diagnoses to include abnormalities of gait and mobility, abnormal posture, fall on the same level, and polyneuropathy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required substantial/maximal assistance with sit to stand and chair/bed-to-chair transfers. Per the MDS, the resident had one fall in the last month, one fall in the last two to six months, and a fracture related to a fall in the last six months. Resident #28's care plan initiated on 02/01/2024, revealed the resident was at risk for falls per the standardized fall scale. An incident report dated 04/04/2024, revealed Resident #28 was found on the floor next to their bed. Per the incident report, the resident stated did not remember if they hit their head. The incident report revealed the resident would be sent to the hospital for further evaluation to rule out internal injuries and/or fractures. Resident #28's History and Physical, from the local hospital with an admit date of 04/04/2024, revealed the resident presented to the hospital after they had a fall. Per the History and Physical, the resident was found to have a thoracic (T) 9 through T11 rib fracture with a subpleural hematoma. Resident #28's care plan initiated on 02/01/2024, revealed the resident was at risk for falls per the standardized fall scale. Interventions initiated on 04/05/2024, revealed the Medical Doctor would review the resident's medication regimen. During an interview on 05/15/2024 at 10:42 AM, the Director of Nursing stated there was not a medication review done after the resident fell on [DATE] to determine if some of the resident's ordered medication attributed to their fall. During an interview on 05/16/2024 at 12:44 PM, the Administrator stated not following up on falls and implementing interventions could result in serious injuries and/or death of a resident.

3. An admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. Resident #11's Order Summary Report, for the timeframe 04/16/2024 to 05/31/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 11:50 AM, Resident #11 was observed lying in bed with oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. On 05/18/2024 at 9:53 AM, Resident #11 was observed in the hall by the nurses' station. The resident had oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. During an interview on 05/14/2024 at 3:12 PM, the Director of Nursing (DON) stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 3:13 PM, the Administrator stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 4:03 PM, Licensed Practical Nurse #9 stated Resident #11 wore supplemental oxygen all the time. During an interview on 05/18/2024 at 10:48 AM, the interim Medical Director stated the staff should not administer supplemental oxygen to a resident without a physician's order. During a follow-up interview on 05/18/2024 at 12:09 PM, the Administrator stated there should be a physician's order for Resident #11's use of supplemental oxygen. During a follow-up interview on 05/18/2024 at 11:18 PM, the DON stated there should be a physician's order for Resident #11's use of supplemental oxygen. Per the DON, the staff failed to ensure the physician's order. Based on observations, interviews, and record reviews, the facility failed to ensure there was a physician's order for the use of supplemental oxygen for 3 (Residents #8. #11, and #23) of 6 sampled residents reviewed for respiratory care. Findings included: 1. An admission Record revealed the facility admitted Resident #8 on 01/19/2024, with diagnoses to include acute respiratory failure with hypoxia, emphysema, pneumonia, and shortness of breath. An admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #8's Order Summary Report, with active orders as of 05/13/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 9:29 AM and 05/14/2024 at 10:16 AM, the surveyor observed Resident #8 had supplemental oxygen on by way of a nasal canula and the oxygen concentrator was in the on position, set a three and a half liters per minute. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing (DON) stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:48 PM, the MDS Coordinator stated there were only two people at the facility who looked at the physician's orders, so apparently either she or the DON missed the physician's order for Resident #8's supplemental oxygen use. During a follow-up interview on 05/17/2024 at 1:07 PM, the DON acknowledged Resident #8 did not have a physician's order for their supplemental oxygen use. Per the DON, it was an oversight on the part of the admission nurse. 2. An admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. had intact cognition. The MDS revealed the resident used oxygen therapy. Resident #23's Order Summary Report, with active orders as of 05/13/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 9:18 AM and 11:52 AM, the surveyor observed an oxygen tank/cylinder in Resident #23's room. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing (DON) stated Resident #23 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #23 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:29 PM, the MDS Coordinator acknowledged there was no physician's order for Resident #23's use of supplemental oxygen. During a follow-up interview on 05/17/2024 at 1:07 PM, the DON acknowledged Resident #23 did not have a physician's order for their supplemental oxygen use. Per the DON, it was an oversight on the part of the admission nurse.

4. An admission Record revealed the facility admitted Resident #21 on 03/21/2023, with a diagnosis to include shortness of breath. Per the admission Record, on 05/10/2024, Resident #21 received a diagnosis of chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2024, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #21's care plan, initiated on 03/29/2023, revealed the resident had shortness of breath. Resident #21's Order Summary Report, that contained active orders as of 05/17/2024, revealed an order dated 08/29/2023, for ipratropium-albuterol inhalation solution, inhale three milliliters orally by way of nebulizer every six hours as needed for chronic obstructive pulmonary exacerbation. On 05/13/2024 at 10:05 AM and 05/16/2024 at 9:00 AM, Resident #21's nebulizer was observed uncovered on the resident's nightstand. During an interview on 05/17/2024 at 1:07 PM, the Director of Nursing stated bags were purchased for all residents to store their oxygen equipment when not in use, so she did not know why there was not a bag in Resident #21's room to store their oxygen equipment. 3. An admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. On 05/13/2024 at 9:56 AM, the surveyor observed Resident #11's oxygen tubing was not stored in a bag and attached to an oxygen concentrator. On 05/13/2024 at 11:52 AM, the surveyor observed Resident #11's nasal cannula directly touched the metal part of the oxygen concentrator and the oxygen tubing was not stored in a bag. During an interview on 05/17/2024 at 4:05 PM, Licensed Practical Nurse (LPN) #2 stated oxygen tubing should be kept off the floor. Per LPN #2, ideally oxygen tubing should be coiled and kept somewhere it would not get dirty. During an interview on 05/17/2024 at 4:28 PM, Registered Nurse (RN) #3 stated oxygen tubing should not touch the floor. Per RN #3, the facility had no bags to store oxygen tubing. During an interview on 05/18/2024 at 10:48 AM, the Interim Medical Director stated ideally oxygen tubing should not touch the floor and it should not encounter high contact surfaces such as a resident's wheelchair handles. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she would expect oxygen tubing to not touch the floor and for the nasal cannula to not touch high-touched surface areas. Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure respiratory equipment was stored in a manner to prevent the spread of infection for 4 (Residents #8, #11, #21, and #23) of 6 sampled residents reviewed for respiratory care. Findings included: The facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised in January 2024, revealed The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The policy specified, 8. Keep the oxygen canulae and tubing used PRN [pro re nata, a Latin phrase that meant as the circumstances arises] off floor or in a plastic bag when not in use. 1. An admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. had intact cognition. The MDS revealed the resident used oxygen therapy. During an observation on 05/13/2024 at 11:52 AM, Resident #23's oxygen tubing and nasal cannula were observed wrapped around the resident's bed rails and uncovered. attached the oxygen concentrator and uncovered, while the resident was noted in the dining room. During an observation on 05/14/2024 at 11:53 AM, Resident #23's nasal cannula and tubing was uncovered on the back of the resident's chair. During an interview on 05/14/2024 at 4:47 PM, Resident #23 stated there use to be a bag to store their nasal cannula and oxygen tubing in, but the bag disappeared some time ago. During an interview on 05/17/2024 at 1:07 PM, the Director of Nursing (DON) stated oxygen tubing should be off the floor and in a bag. The DON stated her expectation was for the nurses and aides to place the oxygen tubing and nasal cannula in the bags provided to keep them covered and clean to help prevent respiratory infections. 2. An admission Record revealed the facility admitted Resident #8 on 01/19/2024, with diagnoses to include acute respiratory failure with hypoxia, emphysema, pneumonia, and shortness of breath. An admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. During an observation on 05/13/2024 at 9:29 AM, Resident #8 had on a nasal cannula that was attached to an oxygen concentrator in their room; however, there was another nasal cannula and oxygen tubing wrapped around the top of the oxygen cylinder that was uncovered. During an observation on 05/13/2024 at 11:59 AM, Resident #8's nasal cannula and tubing remained wrapped around the top of the oxygen cylinder, on the back of the wheelchair, uncovered. During an observation on 05/14/2024 at 10:16 AM, Resident #8's oxygen tubing and nasal cannula remained wrapped around the oxygen cylinder, uncovered. During an observation on 05/14/2024 at 4:12 PM, Resident #8's nasal cannula and tubing wrapped around the oxygen cylinder, uncovered. During an interview on 05/17/2024 at 1:07 PM, the Director of Nursing (DON) stated oxygen tubing should be off the floor and in a bag. The DON stated her expectation was for the nurses and aides to place the oxygen tubing and nasal cannula in the bags provided to keep them covered and clean to help prevent respiratory infections.

Based on interviews, document review, and facility policy review, the facility failed to implement a quality assurance and performance improvement program to evaluate and monitor resident falls in the facility. This deficient practice had the potential to affect all residents who currently resided in the facility. Findings included: A facility policy titled, Quality Assessment and Assurance Plan, revised in December 2009, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation The primary purposes of the Quality Assessment and Assurance Plan are: 1. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. Per the policy, 2. The Administrator is responsible for assuring that this facility's Quality Assessment and Assurance Program complies with federal, state, and local regulatory agency requirements. An undated, untitled typed document presented to the survey team, revealed the facility held a quality assurance (QA) committee meeting on the second Tuesday of each month at 12:00 PM and the QA team lead was the Administrator. During an interview on 05/16/2024 at 12:33 PM, the Director of Nursing (DON) stated she had been working on getting together a QAPI for falls, but it was not currently in place. During a follow-up interview on 05/18/2024 at 6:41 PM, the DON stated the facility did not track and trend residents falls and they only reviewed the fall to make sure interventions were completed (implemented). During an interview on 05/18/2024 at 7:00 PM, the Administrator presented the survey team with a document that detailed a list of residents and when they had fallen. Per the document, during the timeframe of 11/20/2023 to 05/11/2024, Resident #16 had a total of 10 falls, with four of the falls being unwitnessed and Resident #28 had a total of nine falls, with one being an unwitnessed fall. The Administrator stated there was no evidence to indicate any tracking or trending of residents falls in the facility.

Based on interviews and facility policy review, the facility failed to conduct mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program. This deficient practice affected all residents who currently resided in the facility, Findings included: A facility policy titled, Quality Assessment and Assurance Plan, revised in December 2009, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The policy did not address staff training on the facility's QAPI program. During an interview on 05/17/2024 at 5:00 PM, the Director of Nursing (DON) stated there was not specific staff training on QAPI. During an interview on 05/18/2024 at 9:15 AM, the Administrator stated there had not been any staff training on QAPI. During an interview on 05/18/2024 at 9:35 AM, [NAME] Aide #17 stated he was not sure what QAPI was and had not received any training on it. During an interview on 05/18/2024 at 9:41 AM, Certified Nursing Assistant #18 stated she did not know what QAPI was. During an interview on 05/18/2024 at 9:44 AM, Housekeeper #19 stated she had no idea what QAPI was and had never been talked to about it. During a follow-up interview on 05/18/2024 at 11:19 AM, the DON stated she was not aware QAPI training was required for all staff and it was missed because it was not on their policy. During a follow-up interview on 05/18/2024 at 12:07 PM, the Administrator stated she was not aware QAPI training was required for all staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, protein-calorie malnutrition, essential hypertension, hyperlipidemia, anemia, hypothyroidism, major depressive disorder, hallucinations, and pain in left and right feet. Residents medical record was reviewed on 12/12/23. A nursing progress note dated 6/21/23 at 3:55 AM documented, Resident was attempting to get up to go to the restroom, her silent bed alarm went off, the CNA [certified nursing assistant] approached room and heard a clatter she opened the door to find resident on the floor. CNA called for RN [registered nurse] to assist. RN assessed resident c/o [complaints of] pain to right shoulder and right toe. RN and CNA assisted resident into bed and assisted her to change her brief . resident had verbal complaints of pain frequently calling out. RN notified emergency contact #1 and Dr. resident was sent . to ER [emergency room] for assessment and x-ray on right shoulder. Resident left facility at 0352 report was called into the ER. The facility initial entity report form exhibit 358 documented, [resident 2] had fallen getting up during the night and was sent to the ER. She did return to the facility a few hours later. Resident returned from the ER with dx [diagnosis] of right humerus fx [fracture] treated with immobilizer orders. Review of the exhibit 358 entity report documented the staff became aware of the incident on 6/21/23 at 5:00 AM and the administration was notified on 6/21/23 at 7:30 AM. The incident was reported to the SSA on 6/21/23 at 1:16 PM. On 12/12/23 at 3:52 PM an interview with administrator (ADM) was conducted. The ADM stated that she was under the impression that once we had confirmation of a significant injury, like a broke bone, then we begin the investigation process and complete the 358 report 2 hours after that. The ADM stated that once she learned about the resident having a broken bone or serious injury, she would start on the 358 and submitted it within 2 hours. 3. Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertensive encephalopathy, mild cognitive impairment, unsteadiness on feet, abnormal posture, delerium and major depressive disorder. Resident 1's medical record was reviewed. A nurses note dated 8/3/23 at 1:45 AM revealed,Note Text: Diagnosis of hypertensive encephalopathy. She is alert and oriented to person, place, and time. She has slight confusion with some things. She has been education on call light usage. She participates in PT. She is independent to the bathroom and continentof bowel and bladder. She walks around the facility without a cane or walker. She wandered from the facility, found by the police and brought back to the facility. Her husband is currently staying with her. A nurses note dated 8/3/23 at 1:49 AM revealed, Note Text: She had requested a cigarette. A man later came to the facility saying she has wandered from the facility. The man and his wife asked her to come back to the facility and [resident 1] refused. [Resident 1] kept walking farther and police were notified to start a search. She was found by carbon avenue. The family was notified and came to the scene. She was with the family for some time and later came back to the facility. Her husband is currently with her. She is being checked on frequently and door alarms are on. On 8/7/23 at 9:45 AM, an Interdisciplinary Team (IDT) review was conducted. The progress note revealed, IDT review of patient elopement. Patient is a new admitted from hospital. Patient was alert and oriented x3. Patient is a smoker on day of admit the husband had spent the day with her and assisted her with smoking. When husband left staff had assisted patient out to the smoking area for a cigarette and decided to walk home, left through the back gate of back yard. She was found near the pool by a community member that called and alerted staff which they immediately went to her location. The aide continuedto follow her until were able to get her back in the building with the help of officers. patient was more confused than normal. Family was also called and was present when bringing her back to facility. Family reports this is an abnormal behavior for her. Staff immediately implemented Q 5-10 min checks for patient location. Wander guard placed to patient ankle. Patient had found a way to remove the wandergaurd from her ankle. Staff were able to place the device in the cuff of her shoe and new bracelet placed to her wrist. IDT team had conference with family discussion about frequent checks and family involvement including providing activities of choice to help with transition. Family will provide assistance with day time monitoring. Staff will continuewith frequent safety checks. Activities of choice such as puzzles, coloring books and drawings. Attendees: IDT review of patient elopement. Patient is a new admitted from hospital. Patient was alert and oriented x3. Patient is a smoker on day of admit the husband had spent the day with her and assisted her with smoking. When husband left staff had assisted patient out to the smoking area for a cigarette and decided to walk home, left through the back gate of back yard. She was found near the pool by a community member that called and alerted staff which they immediately went to her location. The aide continuedto follow her until were able to get her back in the building with the help of officers. patient was more confused than normal. Family was also called and was present when bringing her back to facility. Family reports this is an abnormal behavior for her. Staff immediately implemented Q 5-10 min checks for patient location. Wander guard placed to patient ankle. Patient had found a way to remove the wandergaurd from her ankle. Staff were able to place the device in the cuff of her shoe and new bracelet placed to her wrist. IDT team had conference with family discussion about frequent checks and family involvement including providing activities of choice to help with transition. Family will provide assistance with day time monitoring. Staff will continuewith frequent safety checks. Activities of choice such as puzzles, coloring books and drawings. On 8/3/23 at 3:00 PM, an exhibit 358 was submitted to the State Survey Agency. The report stated that the incident occurred on 8/2/23 at 8:20 PM. The administrator was made aware of the incident on 8/2/23 at 8:20 PM. Exhibit 359 was reviewed. The report was submitted on 8/10/23 at 2:30 PM, which was outside of the 5 day time limit for investigation reporting. 4. Resident 3 was admitted to the facility initially on 5/18/23 and again on 11/12/23 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, alcoholic liver disease, deep vein embolism and thrombosis of lower right extremity, pancytopenia and orthopedic aftercare. Resident 3's medical record was reviewed. On 5/21/23, a fall risk assessment was completed. The fall risk assessment revealed that resident 3 was a high fall risk. Resident 3's care plan was reviewed. A care area regarding falls, dated 5/19/23, included the following interventions to prevent falls: a. Answer call lights promptly b. Be sure bed is in lowest position and locked in place. c. Assess assistive devices for proper fit and use. d. Continually educate resident regarding safety issues. e. Encourage self-mobile residents to rise slowly and be sure of their steadiness prior to walking. A nurses progress note dated 11/6/23 at 8:42 AM revealed, Resident was found by staff on the floor to the side of her bed, She had pushed her button. Assessment showed pain in the left hip. Unable to move her to her bed. Made her comfortable with pillow under leg. She was comfortable unless moved. Ambulance wascalled and she was transported. Vitals within normal limits. Regular and unlabored respirations. 02 (oxygen concentration) was 93% on RA (room air). A nurses progress note dated 11/6/23 at 10:59 AM revealed, [Hospital Emergency Room] called to report that patient does have a fracture to her L (left) hip. Will tentatively be having surgery today. On 12/12/23 at 12:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a resident sustained a fall and the fall was unwitnessed, the resident was assessed by the nurse on duty and an incident report was initiated. LPN 1 stated the Director of Nursing (DON), Physician, and resident's representative would be notified. LPN 1 stated the DON usually makes the determination if a resident would be sent to the hospital, however, if it was evident that the resident needed immediate care, the nurse on duty could call EMS. LPN 1 stated resident 3's bed was in the low position as per her care plan when she fell. LPN 1 stated resident 3 did not call for assistance to transfer. An exhibit 358 was submitted to the State Survey Agency at 11:20 AM on 11/6/23. The report stated the incident occurred at 7:30 AM on 11/6/23 and the Administrator was made aware at 7:35 AM. The submission was beyond the 2 hour requirement for submission. An exhibit 359 was submitted to the State Survey Agency at 3:18 PM on 11/14/23, which was outside of the 5 day time limit for investigation reporting. Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property for 4 of 7 sample residents were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, the facility did not report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. Resident identifiers: 1, 2, 3, and 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses that included history of falls, aftercare following joint replacement surgery, scalp contusion, polyneuropathy, and protein calorie malnutrition. Resident 7's medical record was reviewed on 12/12/23 On 9/13/23 at 8:07 PM, a nurses note indicated that, RN (Registered Nurse) was walking down the hallway and [resident 7] was sitting on her couch asking for help RN entered her room and asked what she needed help with she states she needs help to her bed she then told the RN that she was brushing her hair and fell to the floor but was able to get herself to her couch. RN assessed her and found no wounds or signs of falling, [Resident 7] was able to stand up with stand by assist and ambulate to her bed with no problems. [Resident 7] was assisted to bed and given a pain pill. Per nurses notes, on 9/14/23 resident 7 was sent to the hospital for pain, and was diagnosed with a urinary tract infection and an acute T11 burst fracture. Review of the facility's form 358 for this incident indicated that although the incident occurred on 9/13/23 at 8:07 PM, the facility Administrator (ADM) was not made aware of the potential abuse and neglect allegation until 9/14/23 at 8:30 AM. Review of the facility's form 359 for this incident indicated that the report was submitted to the State Survey Agency (SSA) on 9/22/23, which was not within 5 working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, protein-calorie malnutrition, essential hypertension, hyperlipidemia, anemia, hypothyroidism, major depressive disorder, hallucinations, and pain in left and right feet. Residents medical record was reviewed on 12/12/23. A nursing progress note dated 6/21/23 at 3:55 AM documented, Resident was attempting to get up to go to the restroom, her silent bed alarm went off, the CNA [certified nursing assistant] approached room and heard a clatter she opened the door to find resident on the floor. CNA called for RN [registered nurse] to assist. RN assessed resident c/o [complaints of] pain to right shoulder and right toe. RN and CNA assisted resident into bed and assisted her to change her brief . resident had verbal complaints of pain frequently calling out. RN notified emergency contact #1 and Dr. resident was sent . to ER [emergency room] for assessment and x-ray on right shoulder. Resident left facility at 0352 report was called into the ER. The facility initial entity report form exhibit 358 documented, [resident 2] had fallen getting up during the night and was sent to the ER. She did return to the facility a few hours later. Resident returned from the ER with dx [diagnosis] of right humerus fx [fracture] treated with immobilizer orders. The facility follow-up investigation report form exhibit 359 documented, Resident [2] returned from ER with dx of right humerus fx . The summary of interview with witnesses stated, Resident was attempting to get up to go to the restroom, her silent bed alarm went off, the CNA approached room and heard a clatter she opened the door to find resident on the floor. CNA called for RN to assist. RN assessed resident c/o pain to right shoulder and right toe. RN and CNA assisted resident into bed and assisted her to change her brief. Neuro checks started. Resident had verbal complaints of pain frequently calling out. RN notified emergency and was sent vis EMS non emergent to ER for assessment and x-ray on right shoulder. Resident left facility at 0352 [3:52 AM] report was called into the ER. The findings of the investigation was documented as inconclusive. No additional interviews from staff and/or resident were documented in the follow-up investigation. On 12/12/23 at 2:24 PM an interview with CNA 1. CNA 1 stated that she came to work the day after resident 2 had fallen and broken her arm. CNA 1 stated that resident 2 had fallen in the past. CNA 1 stated that the interventions to keep resident 2 safe from falls were; resident 2's room was close to the nurses station, the bed had a silent alarm which alerted staff if resident 2 was getting up from her bed, and staff checked on all residents at least every 2 hours, but staff typically checked on resident 2 about every hour. CNA 1 stated that resident 2 had some confusion and would attempt to get up by herself. CNA 1 stated that staff assist resident 2 to the bathroom and resident 2 was typically a 1-person assist. CNA 1 stated that resident 2 was typically able to tell staff if she needed to use the bathroom. On 12/12/23 at 3:53 PM an interview with the administrator (ADM) was conducted. The ADM stated that she did not interview other staff or residents because the fall was unwitnessed. The ADM stated that she did not begin the investigation process for resident 7 until it was confirmed from the hospital that she had a fracture. The ADM stated that she did not have any interviews with staff or residents regarding neglect. 3. Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertensive encephalopathy, mild cognitive impairment, unsteadiness on feet, abnormal posture, delerium and major depressive disorder. Resident 1's medical record was reviewed. A nurses note dated 8/3/23 at 1:49 AM revealed, Note Text: She had requested a cigarette. A man later came to the facility saying she has wandered from the facility. The man and his wife asked her to come back to the facility and [resident 1] refused. [Resident 1] kept walking farther and police were notified to start a search. She was found by carbon avenue. The family was notified and came to the scene. She was with the family for some time and later came back to the facility. Her husband is currently with her. She is being checked on frequently and door alarms are on. An exhibit 359 was submitted to the State Survey Agency on 8/10/23 at 2:30 PM. A summary of the progress note documenting the event was included in the area for Steps taken to investigate. The summary of interviews for staff who had oversight of the resident included that the resident was more conused than usual. It states that the family was notified and present when the resident was returned to the facility and that family stated it was unusual behavior. Corrective action included having an interdisciplinary team meeting and discussion with family about frequent checks on the resident and family involvement. Additional documentation of interviews and education were requested, but were not provided. 4. Resident 3 was admitted to the facility on [DATE] and again on 11/12/23 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, alcoholic liver disease, deep vein embolism and thrombosis of lower right extremity, pancytopenia and orthopedic aftercare. Resident 3's medical record was reviewed. A nurses progress note dated 11/6/23 at 8:42 AM revealed, Resident was found by staff on the floor to the side of her bed, She had pushed her button. Assessment showed pain in the left hip. Unable to move her to her bed. Made her comfortable with pillow under leg. She was comfortable unless moved. Ambulance wascalled and she was transported. Vitals within normal limits. Regular and unlabored respirations. 02 (oxygen concentration) was 93% on RA (room air). An exhibit 359 submitted on 11/14/23 at 3:18 PM included that the resident was a representative for herself. A summary of the interview with the resident stated she was trying to get up for breakfast and tripped on the leg of her wheelchair. It also states that she had not called for help prior to falling. A summary of interviews conducted with staff and others who had knowledge of the incident included that the resident was independent with mobility and transfers and was preparing to discharge home. There were no additional interviews with staff or residents provided. A checklist about the incident was reviewed and included that witness statements were taken and staff education was provided, however, the information was not included with exhibit 359 and was not provided with additional requested documents. Based on interview and record review, the facility did not ensure that all allegations of abuse were thoroughly investigated. Specifically, the facility completed a form 359 as a summary for allegations of abuse, but did not have additional evidence of the complete investigation for 4 of 7 sample residents. Resident identifiers: 1, 2, 3 and 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses that included history of falls, aftercare following joint replacement surgery, scalp contusion, polyneuropathy, and protein calorie malnutrition. Resident 7's medical record was reviewed on 12/12/23 On 9/13/23 at 8:07 PM, a nurses note indicated that, RN (Registered Nurse) was walking down the hallway and [resident 7] was sitting on her couch asking for help RN entered her room and asked what she needed help with she states she needs help to her bed she then told the RN that she was brushing her hair and fell to the floor but was able to get herself to her couch. RN assessed her and found no wounds or signs of falling, [Resident 7] was able to stand up with stand by assist and ambulate to her bed with no problems. [Resident 7] was assisted to bed and given a pain pill. Per nurses notes, on 9/14/23 resident 7 was sent to the hospital for pain, and was diagnosed with a urinary tract infection and an acute T11 burst fracture. The facility's form 359 for this incident was reviewed. Under the section Summary of interview(s) with witness(es), what the individual observed or knowledge of the alleged incident or injury, the facility staff wrote what the nurses note stated of the incident on 9/13/23. The facility did not provide additional documentation of specific interviews that were completed as part of the investigation, if any, in addition to what was documented in the resident record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, facility staff administered intravenous (IV) medications without being certified to administer intravenous medications to 2 of 7 sampled residents. Resident identifiers: 1 and 2. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included sepsis, methicillin resistant staphylococcus aureus (MRSA), psoas muscle abscess, osteomyelitis of the vertebrae, muscle weakness, malnutrition, human immunodeficiency virus, malignant neoplasm of anus, syphilis, and anxiety. On 3/30/23 the medical record of resident 1 was reviewed. A physician's order dated 1/14/23 revealed Vancomycin HCl (hydrochloride) Intravenous Solution. Use 1 gram intravenously one time a day for MRSA. A physician's order dated 1/13/23 revealed Sodium Chloride 0.9% (percent) 10 ml flush every shift for maintenance. A physician's order dated 1/24/23 revealed, Heparin Lock Flush Solution 100 UNIT/ML (milliliter). Use 5 ml intravenously one time a day for PICC (peripherally inserted central catheter). The January, February and March Medication Administration Records (MARs) for resident 1 documented that the Vancomycin had been administered intravenously by a staff member who was not IV certified on the following dates: a. 1/15, 1/16, 1/17, 1/18, 1/21, 1/22, 1/25, 1/27, 1/28, and 1/31 b. 2/1, 2/2, 2/5, 2/7, 2/8, 2/11, 2/12, 2/14, 2/16, 2/17, 2/21, 2/22, 2/27, and 2/28 c. 3/1 and 3/2 The MAR for resident 1 documented that the Sodium Chloride flush solution had been administered intravenously by a staff member who was not IV certified on the following dates: a. 1/15, 1/16, 1/17, 1/21, 1/22, 1/25, 1/27 and 1/31 b. 2/1, 2/2, 2/5, 2/7, 2/8, 2/9, 2/11, 2/12, 2/14, 2/16, 2/17, 2/21, 2/22, 2/27 and 2/28 c. 3/1, 3/2, 3/4, 3/5, 3/7, 3/9, 3/10, 3/11 and 3/15 The MAR for resident 1 documented that the Heparin flush solution had been administered intravenously by a staff member who was not IV certified on the following dates: a. 1/26, 1/28 and 1/31 b. 2/1, 2/2, 2/3, 2/5, 2/7, 2/8, 2/11, 2/12, 2/14, 2/16, 2/17, 2/21, 2/22, 2/25, 2/27, and 2/28 c. 3/1, 3/2, 3/5, 3/7, 3/9, 3/11 and 3/15 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, emphysema, asthma, chronic obstructive pulmonary disease, malnutrition, type II diabetes, Parkinson's disease, and major depressive disorder. On 3/30/23 the medical record of resident 2 was reviewed. A physician's order dated 3/4/23 revealed Ertapenem Sodium solution 1 GM (gram). Use 1 GM intravenously every 24 hours. The March 2023 MAR for resident 2 documented that the Ertapenem Sodium solution had been administered intravenously by a staff member who was not IV certified on the following dates: a. 3/4, 3/5, 3/7, 3/8, 3/9, and 3/10. On 3/30/23 at 9:45 AM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated the facility did not have any Licensed Practical Nurses (LPNs) who were IV certified and that she had been trying to get the facility to get them certified for a long time. On 3/30/23 at 11:27 am, an interview was conducted with LPN 1. LPN 1 stated he did not do anything with the IVs. LPN 1 stated it would be the Director of Nursing (DON) or one of the other Registered Nurses (RNs). LPN 1 stated the nurse who administered the IV medication or flush should have charted it in the MAR. LPN 1 stated the nurse who administered the medication should have charted the flushes and everything. LPN 1 stated that he was not IV certified and only IV certified staff could take care of a residents IV. On 3/30/23 at 11:28 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated they put an RN on duty during each shift and if there is not an RN on duty then the DON would be there to administer any IV medication. The CRN stated it was the expectation of the facility that the nurse who administered the medication would also chart that the medication had been given. On 3/30/23 at 11:50 AM, an interview was conducted with the Director of Nursing In Training (DONIT). The DONIT stated the RNs are the only staff who do anything with the IVs. The DONIT stated the LPNs would obtain the IV medication or flush from the medication supply room and give it to the RN to administer. The DONIT stated the LPN who obtained the medications was also the staff member who would document the administration of the IV medication in the medical record. The DONIT stated sometimes the administering RN would write a progress note in the medical record, but not always. The DONIT stated the RNs were expected to chart any medications that they administered, including IV medications. And that the charting of the administration of IV medications should not be done by any staff who did not administer the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the residents right to participate in the development and implementation of his or her person-centered plan of care. Specifically, for 1 out of 20 sampled residents, a resident that was admitted to the facility on [DATE], had not had a care conference and the resident was unsure what the plan of care consisted of. Resident identifier: 16 Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16 stated that he was upset because he had been a resident at the facility for over a month and he was unsure of what his plan of care consisted of. Resident 16 stated that he did not know why he was at this facility, and that he did not have any meetings with staff concerning his plan of care. On 12/13/22, resident 16's medical record was reviewed. It was revealed that multiple sections in resident 16's care plan were incomplete. a. The first incomplete focus area stated, The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t [related to]. The specific location was not filled out and there was no information given about what the impairment was related to. The goal for this care area stated, The resident's skin injury (SPECIFY) of the (location) will be healed by review date. There was no information given about the specific skin injury or location. The interventions section was left blank. b. The second incomplete focus area stated, Resident requires long term care services related to: There was no further information given. The goal section was left blank. The intervention stated, Provide Care Conference for residents and families. c. The third incomplete focus area stated, The resident has Peripheral Vascular Disease (PVD) r/t. There was no further information given. The goal and the intervention were left blank. d. The fourth incomplete focus area stated, The resident has shortness of breath (SOB) r/t. There was no further information given. The goal stated, The resident will have no complications related to SOB through the review date. The intervention section was left blank. e. There was no behavioral care plan for resident 16's diagnosis of post-traumatic stress disorder. f. There was no behavioral care plan for the resident 16's diagnosis of Major Depressive Disorder. A progress note dated 11/9/22 at 8:57 AM, stated, Care Conference: Attempted to hold care conference for [Resident 16]. He was lying in bed asleep. Asked [resident 16] if he wanted to have conference and he said no. Will attempt at a later day. A review of resident 16's progress notes revealed there were no further attempts to have a care conference with resident 16. On 12/14/22 at 2:16 PM, an interview with the Resident Advocate (RA) was conducted. The RA stated that the goal for new residents was to hold a care conference within the first seven days of the resident being at the facility. The RA stated that after the first care conference, the residents would then have a care conference every three months. The RA stated that care conferences were held to go over the residents' goals and their plan of care. The RA stated that she was unaware if resident 16 ever had a care conference. The RA stated that resident 16 did not want to participate in the first scheduled care conference and she did not know if the meeting was rescheduled. On 12/15/22 at 9:22 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she had a one-on-one care conference with resident 16 on 12/5/22. It should be noted that 12/5/22, would have been 24 days after resident 16 was admitted to the facility. The DON stated that she spoke with resident 16 about what cares he wanted and his current goals. The DON stated that she did not know if there was any documentation of the care conference. A review of resident 16's medical record revealed that there was no documentation of a care conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, for 2 out of 20 sampled residents, a resident was incorrectly coded as not having a Traumatic Brain Injury (TBI) and a resident was incorrectly coded as being discharged to the hospital. Resident identifiers: 15 and 26 Findings included: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. Resident 15's admission MDS assessment dated [DATE], was marked No for resident 15 having a TBI. On 12/13/22 at 2:43 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that she was responsible for filling out the resident MDS assessments. The ADON stated that the MDS for resident 15 should have been marked Yes for having a TBI. 2. Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include chronic osteomyelitis, non-pressure chronic ulcer, chronic respiratory failure with hypoxia, cellulitis, sepsis, prediabetes, hyperlipidemia, bipolar disorder, anxiety disorder, and plantar fascial fibromatosis. Resident 26's discharge MDS assessment dated [DATE], was coded as being discharged to an acute hospital. A progress note dated 10/21/22 at 12:06, titled Discharge Summary revealed that resident 26 was discharged home. On 12/13/22 at 2:43 PM, an interview with the ADON was conducted. The ADON stated that resident 26 had discharged home but was accidentally coded as being discharged to a hospital on the discharge MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 2 out of 20 sampled residents, a resident's care plan was left blank in multiple sections and a resident's wound care plan was not updated. Resident identifiers: 16 and 80. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16 stated that he was upset because he had been a resident at the facility for over a month and he was unsure of what his plan of care consisted of. Resident 16 stated that he did not know why he was at this facility, and that he did not have any meetings with staff concerning his plan of care. On 12/13/22, resident 16's medical record was reviewed. It was revealed that multiple sections in resident 16's care plan were incomplete. a. The first incomplete focus area stated, The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t [related to]. The specific location was not filled out and there was no information given about what the impairment was related to. The goal for this care area stated, The resident's skin injury (SPECIFY) of the (location) will be healed by review date. There was no information given about the specific skin injury or location. The interventions section was left blank. b. The second incomplete focus area stated, Resident requires long term care services related to: There was no further information given. The goal section was left blank. The intervention stated, Provide Care Conference for residents and families. c. The third incomplete focus area stated, The resident has Peripheral Vascular Disease (PVD) r/t. There was no further information given. The goal and the intervention were left blank. d. The fourth incomplete focus area stated, The resident has shortness of breath (SOB) r/t. There was no further information given. The goal stated, The resident will have no complications related to SOB through the review date. The intervention section was left blank. e. There was no behavioral care plan for resident 16's diagnosis of post-traumatic stress disorder. f. There was no behavioral care plan for the resident 16's diagnosis of Major Depressive Disorder. On 12/14/22 at 10:01 AM, an interview with the Resident Advocate (RA) was conducted. The RA stated that she would expect a care plan for post-traumatic stress disorder and depression for residents with those diagnoses. On 12/14/22 at 1:46 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that she completed the resident care plans. The ADON stated that if a resident had a diagnoses of post-traumatic stress disorder or depression, the resident would have a care plan for those diagnoses. The ADON stated that she looked at resident 16's care plan and stated that it was incomplete. The ADON stated that the facility was trying to catch up on completing care plans. On 12/15/22 at 9:22 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that a resident with depression and or post-traumatic stress disorder should have a care plan. The DON stated that she was aware that some care plans were not completed. The DON stated that completing care plans was something that the staff needed more education on. 2. Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left artificial hip joint, acute respiratory failure, moderate protein-calorie malnutrition, difficulty in walking, benign prostatic hyperplasia, obstructive and reflux uropathy, hypertension, dementia, and acute kidney failure. Resident 80's medical record was reviewed on 12/13/22. On 11/9/22 at 5:36 PM, a Nurses Note documented cna [Certified Nursing Assistant], [name removed], reported a sore to resident's right heal [sic]. looks like it was a blister that broke open. placed a bandage on it. On 11/10/22 at 2:39 PM, a Nurses Note documented Notified [name of primary care physician removed] of sores on bilat [bilateral] heels. Orders given to place foam heel protectors when resident in bed and in wheelchair. Apply optifoam dressing and change MWF [Monday, Wednesday, Friday]. Both appear to be blister from resting heels of feet on wheelchair. No bleeding or drainage noted. The Order Summary Report was reviewed. A physician's order dated 11/10/22, documented Foam heel protectors while resident in bed or in wheelchair. Optifoam dressing to bilat heels. [Note: The order did not include a start date.] The November 2022 Treatment Administration Record (TAR) was reviewed. The physician's order for the heel treatment was unable to be located on the TAR. A care plan Focus initiated on 11/14/22, documented The resident has potential/actual impairment to skin integrity of the (bilat hip surgical incision, blister bilat heels ) r/t [related to]. The interventions initiated on 11/14/22, included: a. Foam heel protecting boots while in bed and while in wheelchair. b. Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury). c. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to Medical Director. [Note: The care plan was not updated with the treatment orders.] On 12/14/22 at 2:14 PM, an interview was conducted with the ADON. The ADON stated the staff had a morning stand up meeting and they would go over anything new with a resident. The ADON stated if a resident had a fall, a risk meeting would be held and interventions would be added to the care plan. The ADON stated she would update the resident care plans within 24 hours. On 12/14/22 at 2:16 PM, an interview was conducted with the Wound Nurse. The Wound Nurse stated that the wound specialist came to the facility once a week and the Wound Nurse did rounds with the wound specialist. The Wound Nurse stated that the wound specialist addressed everything skin related even surgical wounds. The Wound Nurse stated every time a resident dressing was changed, which was three times a week, the resident care plan would be updated or at least reviewed. On 12/15/22 at 1:01 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated a resident baseline care plan would be completed on admission. The RNC stated the Minimum Data Set nurse would complete the comprehensive care plan within two weeks after admission. The RNC stated the Wound Nurse would update the resident care plan at the time the wound was discovered. The RNC stated the resident care plan should be updated with any changes. The RNC further stated the staff went through the resident care plans quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficult, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, for 1 out of 20 sampled residents, a resident with a diagnoses of post-traumatic stress disorder and major depressive disorder who expressed adjustment difficulties was not offered behavioral health services. Resident identifier: 16 Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16 stated that he was upset because he had been a resident at the facility for over a month and he was unsure of what his plan of care consisted of. Resident 16 stated that he did not know why he was at this facility, and that he did not have any meetings with staff concerning his plan of care. Resident 16 stated that he felt like he was going to die at this facility. Resident 16 stated that he felt like he was in a prison. A review of resident 16's medical record was conducted on 12/13/22. Resident 16's Minimum Data Set (MDS) assessment dated [DATE], was reviewed. The MDS assessment revealed that resident 16 had an anxiety disorder, depression, schizophrenia, and post traumatic stress disorder. A Preadmission Screening Resident Review (PASRR) Level II dated 10/14/22, was reviewed. It should be noted that the PASRR Level II form was filled out while resident 16 was located at a different facility. Recommendations on the PASRR Level II form included: a. [Resident 16] would benefit from individual therapy and medication management. He is still an open client through [therapy provider name redacted] and could possibly benefit from these services while at the nursing facility. b. Psychosocial needs identified included, cognitive stimulation, need for insight and education, socialization, and support. Resident 16's care plan was reviewed. There was no behavioral care plan for resident 16's diagnosis of post-traumatic stress disorder or major depressive disorder. Resident 16's progress notes revealed behavioral concerns. a. A progress note dated 11/4/22 at 12:34 PM, stated, resident has been in bed with his cap over his face and blankets up over his head and doesn't respond when talked to. Very aggressive in taking the cup of his pill. b. A progress note dated 11/4/22 at 2:33 PM, stated, After lunch on Thursday November 3, 2022, Resident was at Nursing Station complaining of being 'in a prison.' Several staff members were trying to calm him down. Administrator [name redacted] tried to intercede. [Resident 16] turned his anger towards Administrator. He struck Admin [Administrator] in the chest and began pommeling Admin's torso and arms with his fist. Police were called. When they spoke with [resident 16], he calmed down and agreed to cooperate, including taking his medicine. c. A progress note dated 11/21/22 at 10:16 AM, reported that resident 16 was highly aggressive. d. A progress note dated 12/5/22 at 11:58 PM, reported that resident 16 had increased agitation. e. A progress note dated 12/9/22 at 1:34 PM, stated, Resident refused medications, shower and linen change. He said he doesn't like being told what to do and that it is none of anyone's business. Nurse and Admin let him know that because he is here so he is our business. Resident got upset and went out to the back courtyard. Later come inside and went to his room. On 12/14/222 at 9:50 AM, a follow-up interview with resident 16 was conducted. Resident 16 stated that the facility had not offered any behavioral services or therapy. On 12/14/22 at 10:01 AM, an interview with the Resident Advocate (RA) was conducted. The RA stated that she would expect a care plan for post-traumatic stress disorder and depression. The RA stated that resident 16 refused behavioral services. The RA stated that she did not document any attempted measures for getting resident 16 behavioral health services. The RA stated she did not document any refusals by resident 16. On 12/14/22 at 11:59 PM, an interview with the Licensed Clinical Social Worker (LCSW) was conducted. The LCSW stated that resident 16 had been receiving mental health services at his last facility but she was not sure if resident 16 had been offered behavioral health services while at this current facility. On 12/14/22 at 1:46 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that she completed the resident care plans. The ADON stated that if a resident had a diagnoses of post-traumatic stress disorder or depression, the resident would have a care plan for those diagnoses. The ADON stated that she looked at resident 16's care plan and stated that it was incomplete. The ADON stated that the facility was trying to catch up on completing care plans. On 12/15/22 at 9:22 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that a resident with depression and or post-traumatic stress disorder should have a care plan. The DON stated that she educated staff on what to do if resident 16 expressed aggressive behaviors. The DON stated she was unsure if the RA had reached out to behavioral health services for resident 16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 20 sampled residents, a resident's diuretic medication used to treat high blood pressure was not monitored according to the physician's ordered parameters. In addition, a resident's angiotensin-converting enzyme medication to treat high blood pressure was not monitored according to the physician's ordered parameters. Resident identifiers: 2 and 84. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, lymphedema, heart failure, dysphasia, major depressive disorder, and generalized edema. On 12/13/22 at 8:14 AM, an observation was conducted of resident 2. Resident 2 was sitting in her motorized wheelchair and her hands and feet bilateral were observed to be swollen. Resident 2's medical record was reviewed on 12/14/22. A physician's order dated 10/18/22, documented Torsemide Tablet 20 MG [milligrams] Give 60 mg by mouth two times a day for Edema management hold for sbp [systolic blood pressure] < [less than] 90 or hr [heart rate] <50. The December 2022 Medication Administration Record (MAR) was reviewed. The Torsemide medication was scheduled to be administered at 6:00 AM and 1:00 PM. The 6:00 AM, administration did not include the SBP or HR prior to the medication being administered. The 1:00 PM, administration did not include the HR prior to the medication being administered. On 12/15/22 at 9:57 AM, an interview was conducted with Assistant Director of Nursing (ADON). The ADON stated if there was a heart next to the medication on the MAR, the heart would indicate monitoring of vital signs. The ADON stated the Torsemide medication had BP monitoring for the evening dose but there was no monitoring on the MAR for the morning dose. The ADON stated that the order was combined on the MAR. The ADON stated that without the monitoring on the MAR the staff would not know if they should administer the medication or not. The ADON stated if the staff were going through the physician's order and reading the medication Rights then it would not be a problem if the monitors were not there because the staff would know to get the residents vital signs prior to the medication administration. 2. Resident 84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease, Alzheimer's disease, dementia, psychotic disorder with delusions, asthma, essential hypertension, and low back pain. Resident 84's medical record was reviewed on 12/14/22. A physician's order dated 12/1/22, documented Enalapril Maleate Tablet 10 MG Give 10 mg by mouth at bedtime for HTN [hypertension] hold for sbp<90 or hr<50. The December 2022 MAR was reviewed. The Enalapril medication was scheduled to be administered at 8:00 PM. The 8:00 PM, administration did not included the SBP and HR prior to the medication being administered. On 12/15/22 at 9:49 AM, an interview was conducted with the ADON. The ADON stated the resident vital signs should be done, every time, prior to the administration of the medication so as not to bottom the resident out. The ADON stated that she would obtain the resident vital signs right before administering the medication. The ADON stated the Enalapril did not have a heart next to it on the MAR so the system would not make the staff obtain a blood pressure prior to the administration. The ADON stated that the Director of Nursing entered the medication orders. The ADON stated the system would not let staff give the medication until they entered the blood pressure if there was a heart on the MAR next to the medication. On 12/15/22 at 10:21 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that medication parameters were inside the physician's orders under additional documentation. The RNC stated the BP would be on the MAR. The RNC stated there were pharmacy guidelines for the vital sign parameters but it would depend on the person, the physician, and the pharmacy. The RNC stated the staff would not see to obtain the resident vital signs if they were not on the orders. The RNC confirmed that resident 84 did have resident specific parameters on the physician's order. The RNC stated the parameters would be entered under supplemental documentation or there would be a progress note. The RNC was unable to find additional documentation that resident 84's vital signs were done prior to the medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 20 sampled residents, a resident taking a psychotropic medication that was initiated on 3/30/22, had not received a GDR and the medication was not clinically contraindicated. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, senile degeneration of brain, dementia, major depressive disorder, atrial fibrillation, encephalopathy, essential hypertension, and muscle weakness. Resident 10's medical record was reviewed on 12/15/22. A physician's order dated 3/30/22, documented Sertraline HCl [hydrochloride] Tablet 100 MG [milligrams] Give 2 tablet by mouth one time a day for depression. The Psychotropic Drug Review dated 9/13/22, documented Sertraline 100 mg, two tablets daily. The current dose of this medication was an increase and the start date of the dose was 8/9/22. [Note: Resident 10 had not had a dosage change since the initiation of the medication on 3/30/22.] The Psychotropic Drug Review dated 11/8/22, documented Sertraline 200 mg daily. The date of the last reduction was 3/30/22. [Note: Resident 10 admitted to the facility on [DATE], and the medication was initiated on 3/30/22.] On 12/15/22 at 12:28 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 10 has had less behaviors then he use to. The ADON stated that resident 10 asked the Regional Nurse Consultant (RNC) today if she would have sex with him. The ADON stated that she had not heard that out of resident 10 in a long time. The ADON stated that resident 10 would kick and scream. The ADON stated that resident 10 was very particular with who and when he freaked out. The ADON stated that resident 10 would scream at the Certified Nursing Assistants all the time. The ADON stated that she had suggested in-services for staff regarding resident behaviors. The ADON stated that sometimes she was involved in the process with GDRs. The ADON stated that resident 10 was stable and maintained and they would review resident 10 in 90 days. The ADON stated that this week would have been the psychotropic meeting and the pharmacist did review resident 10's chart. The ADON stated when the residents were stable the staff want them to stay stable and not have behaviors. The ADON stated when resident 10 first admitted to the facility he was a mess and had several behaviors. The ADON stated in her opinion she would not GDR resident 10's medications. On 12/15/22 at 1:01 PM, an interview was conducted with the RNC. The RNC stated the pharmacist had talked about resident 10 on two occasions and stated that he should have done a GDR with resident 10's Sertraline. The RNC stated she could not find a GDR on resident 10's Sertraline. Additional information was provided by the facility on 12/20/22, after the survey had been concluded. The Physician Rationale for Clinically Contraindicated Gradual Dose Reduction or Duplicative Medication: Sedative/Hypnotic was dated 12/19/22. The form documented the medication in consideration was Sertraline. The target symptoms and distressed behavior demonstrated was cooperative behavior and participation in activities. The box Gradual Dose Reduction (GDR)/Dose Tapering is Clinically Contraindicated was checked. The rational for dose duration greater than typically recommended documented Currently decreasing dose of risperidone If [name of resident 10 removed] tolerates well will begin GDR of Sertraline. [Note: The risperidone was discontinued on 5/6/22.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents were free of significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident returning from the hospital missed two doses of a seizure medication that was prescribed by the physician at the hospital. Resident identifier: 15 Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. Resident 15's medical record was reviewed. A progress note dated 12/13/22 at 11:50 AM, stated, Resident having a seizure that lasts 2 minutes, came to and was A&O [alert and oriented] x 4 [oriented to person,place, time and event]. Started another seizure that started at 12:03 [PM] and has not responded. A progress note dated 12/13/22 at 12:05 PM, stated, While completing walking rounds RN [Registered Nurse] heard CNA [Certified Nursing Assistant] ask resident if he was okay, RN walked into room to find resident laying half on bed convulsing. RN lifted legs onto bed to make resident comfortable. RN stayed with resident until convulsing subsided assessed residents eyes non-reactive to light obtained set of vitals, started neuro [neurological] checks resident stated he hit his head on the wall. No injuries noted upon assessment. [Doctors name redacted] in the facility and assessed resident executive decision to send residents to the ER [Emergency Room] for CT [computerized tomography] scan. A progress note dated 12/13/22 at 12:41 PM, stated, Resident had another seizure that started at 12:19 [PM], convulsing, pupils non-reactive. Ambulance arrived at 12:20 [PM]. [Resident 15] still not responding. Transferred him to stretcher, still not responding. In care of ambulance crew. Left at 12:32 [PM]. A progress note dated 12/14/22 at 11:15 AM, stated, Resident returned from [hospital name redacted] at 12:35 [PM] transported by out [sic] transport driver. Came into the building in wheelchair with staff pushing him. Alert and oriented to self, situation, and place. He is on regular diet and regular texture .Kepprais [sic] a new order from the hospital. He needs follow up in 2 weeks . A document titled Patient Discharge Summary Report Dated 12/14/22 and time stamped 9:39 AM, revealed that resident 15 had a new medication order. The new medication order was for Levetiracetam (Keppra) 500 milligrams (mg) by mouth twice a day. The document stated that the last dose given was at 12/14/22 at 8:40 AM. On 12/15/22 at 10:55 AM, an interview with the Medical Director (MD) was conducted. The MD stated that resident 15 was started on Keppra due to the recent seizures. Resident 15's physician's orders were reviewed. It was revealed that Levetiracetam (Keppra) was not listed as one of resident 15's medications. On 12/15/22 at 1:00 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that when a resident returned from the hospital, the new medication orders were added to the residents' orders immediately. The ADON stated that the new orders for resident 15's Keppra should have been added to his medication list because she entered the orders in when resident 15 returned to the facility. The ADON reviewed his current medication list and saw that the new order for Keppra was not listed. The ADON stated that the order could have been missed. On 12/15/22 at 1:12 PM, resident 15's medication orders were updated, and it was revealed that Levetiracetam (Keppra) Tablet 500 mg given by mouth two times a day was added to resident 15's medications. It should be noted that resident 15 missed two doses of Levetiracetam (Keppra) 500 mg since returning from the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not obtain routine dental services to meet the needs of the resident. Specifically, for 1 out of 20 sampled residents, a resident with missing teeth, gum swelling, reported pain, and had a recommendation from the Speech-Language Pathologist (SLP) was not provided dental services for six months. In addition, the resident had not been scheduled for the extractions and the last dental visit was in November 2022. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encounter for surgical aftercare following surgery on the genitourinary system, hydronephrosis with ureteral stricture, calculus of kidney, type 2 diabetes mellitus, sepsis due to Escherichia Coli, atrial fibrillation, hypertension, acute kidney failure, pain, and anxiety disorder. On 12/12/22 at 3:25 PM, an observation was conducted of resident 12's teeth. Resident 12 was missing teeth and they were observed to be decayed. Resident 12 stated that she did not want to talk about her teeth. Resident 12 stated that she saw a dentist before the pandemic and the dentist was going to extract all of her teeth. Resident 12 stated that the dentist pulled half of her teeth out prior to the pandemic and then the dentist died. Resident 12 stated another dentist was going to finish pulling her teeth but he wanted to do the dental work while she sat in her wheelchair because she would be unable to get into the dental chair. Resident 12 stated the in house dentist came to the facility but she never got to see him. Resident 12 stated other residents were in line for the dentist but the staff did not come get her. Resident 12 stated that her teeth hurt intermittently. Resident 12's medical record was reviewed on 12/14/22. The admission Minimum Data Set assessment dated [DATE], documented that resident 12 had obvious or likely cavities or broken natural teeth. The care plan focus initiated on 3/4/19 and revised on 9/28/22, documented [Name of resident 12 removed] has poor dentition/broken teeth, resident doesn't like the MS [mechanical soft] texture. The goal initiated on 3/4/19 and revised on 12/12/22, documented [Name of resident 12 removed] will be free of infection, pain or bleeding in the oral cavity by review date. The interventions included: a. Initiated on 6/26/19 and resolved on 6/23/22, RESOLVED: 6/26/19 [Name or resident 12 removed] had teeth extracted on 6/25/19: No rinse of oral cavity for 24 [hours] then rinse with warm salt water solution. No sucking from straw and soft diet for a week. Sleep reclined during recovery- resident prior to teeth extraction prefers to sleep in recliner every night. b. Initiated on 3/4/19, Administer medications as ordered. Monitor/document for side effects and effectiveness. c. Initiated on 3/4/19, Coordinate arrangements for dental care, transportation as needed/as ordered. d. Initiated on 3/4/19, Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. On 5/3/22 at 2:56 PM, a Therapy Notes documented SLP completed facility-requested swallowing assessment to ensure patient safety and determine efficacy of current diet texture. The patient stated that she had begun process of extraction in preparation for dentures however her dentist passed away. She currently is missing upper and lower molars on the left with upper right molars broken. She had gum swelling and reported pain in a front lower incisor. She demonstrated increased mastication time with solid textures. SLP recommends diet upgrade from NDD3 [National Dysphagia Diet level 3] to regular easy to chew textures at this time as the patient enjoys and can safely tolerate french toast and other soft breads. SLP also recommends a dentist consult. No swallowing treatment to be provided at this time. Oral impairment is related to dentition. On 6/21/22 at 1:37 PM, a Care Conference documented Care Conference: [Name of resident 12 removed] care conference held today. [Name of resident 12 removed] states she needs to have f/u [follow up] appt [appointment] with dentist. She would like to continue plan to pull teeth and get dentures. Suggested either using [NAME] [sic] chair for next appt or going to surgical center if appropriate. [Name of resident 12 removed] expressed a dislike for the food. She states she likes when she is served Mexican. She states she has no s/s [signs or symptoms] of UTI [urinary tract infection] at this time. Has completed oral abx [antibiotics]. On 12/15/22 at 10:07 AM, an interview was conducted with the Business Office Manager (BOM). The BOM stated the facility was partnered with a mobile dental care and they would come into the facility to do dental cleanings. The BOM stated the mobile dental care would also do cavities but they were pretty new to the facility. The BOM stated the mobile dental care would come back to the facility with notes and recommendations for extractions. The BOM stated if the resident was not on the dental care the BOM would schedule with the resident's dentist. The BOM stated that the Director of Nursing (DON) would give her a sticky note regarding resident appointments and the BOM would schedule the appointments. The BOM stated there were certain insurance requirements to be on the dental care. The BOM stated the dental care was for long term care residents with Medicare or Medicaid. The BOM stated that the mobile dental care came to the facility and spoke to the residents about the dental program. The BOM stated the residents had to sign up for the dental program in order to receive services. The BOM checked her computer and stated that resident 12 was in the process of signing up for the dental care. The BOM stated that resident 12 had been in the process since the end of October 2022. The BOM stated the dental care would send the paper work to the resident's family members. The BOM stated the dental care should have sent the packet to resident 12 if she was alert and oriented and her own representative. The BOM stated that sometimes the families were overwhelmed with the paperwork and the BOM helped them complete the paperwork if they brought it into the facility. On 12/15/22 at 10:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the facility had a dental care service that came to the building to check all the residents. The ADON stated that resident 12 had mentioned wanting to get all of her teeth pulled to get dentures. The ADON stated the process of removing resident 12's teeth was started prior to the pandemic and the dentist had to stop. The ADON stated that she thought resident 12 was on the dental list to get started again. The ADON stated that the Resident Advocate (RA) would be the one to get the residents on the dental list. On 12/15/22 at 11:49 AM, an interview was conducted with the RA. The RA stated the facility just started with the mobile dental care and they covered Medicaid patients. The RA stated the mobile dental care were just in the facility on 12/2/22. The RA stated that all Medicaid residents were signed up for the dental care. The RA stated the mobile dental care came to the facility in November 2022 to see who wanted to be seen. The RA stated the facility was contracted with a local dentist for dental work. The RA stated if a resident had a toothache the RA would go to the BOM and look over the transport schedule to see what was available and make an appointment. The RA stated that she would keep record of who was seen by the dental care. The RA stated that resident 12 was signed up with the dental care program. The RA referenced her dental list and stated that resident 12 was not seen by the mobile dental care on 12/2/22. The RA stated that resident 12 had an exam by the mobile dental care on the 11/11/22. The RA stated the mobile dental care had not given her a recommendation on a dentist as of yet for resident 12. The dental list was reviewed and resident 12 was seen by the mobile dental care on 11/11/22. The notes section documented that resident 12 had a complete exam and was missing 13 teeth. [Resident 12] would like to have remaining teeth extracted and get an upper and lower complete dentures. There was no documentation under the next visit section. On 12/15/22 at 2:07 PM, a follow up interview was conducted with the RA. The RA stated that she had just called the mobile dental care and had left a message and was waiting for them to call back regarding resident 12. The RA stated that resident 12 had refused the extractions because resident 12 did not want to have the extractions done in her wheelchair. Additional information was provided by the facility on 12/20/22, after the survey had been concluded. On 12/19/22 at 11:52 AM, a Care Conference note was created and documented To give further explanation. [Name of resident 12 removed] had stated that she wanted to remain in her own chair for the procedure of having her teeth removed. The dentist had stated due to the nature of the procedure she would not be able to remain in her own chair. Since [name of resident 12 removed] is Non weight bearing and the dentist does not have a lift, that would not be possible. Further appt were canceled until a resolution could be found. Currently seeking contract with [name of dental company removed] services. Hoping they can find a solution. Follow up to: 06/21/2022 13:37 [1:37 PM] Care Conference. On 12/20/22 at 9:36 AM, a Nurses Note was created and documented [Name of dental care removed] dentist in the building to perform cleanings and follow up dental care. [Name of resident 12 removed] states she does not wish to get up at this time. [Note: The note created by the DON was in reference to a note effective 12/2/22 at 9:36 AM. This note was unable to be located during the survey.]

Based on observation and interview, it was determined that the facility did not store, prepare, and distribute food in accordance with professional standards for food services safety. Specifically, a staff member was observed not sanitizing or changing gloves while distributing food in the dining room. On 12/12/22 at 12:00 PM, the lunch dining service in the main dining room was observed. a. At 12:05 PM, the Dietary Aide (DA) was observed to serve a resident in the main dining area their lunch tray. The DA was observed to have disposable medical gloves on. The DA was observed to enter the kitchen after serving a resident, adjusted her surgical mask, did not change the gloves or sanitize her hands. b. At 12:10 PM, the DA was observed to serve a resident in the main dining area their lunch tray. The DA was observed to have disposable medical gloves on. The DA removed the covering on the fruit cup, scratched her face, and returned to the kitchen to get the resident a juice drink. The DA was observed to return to the kitchen and did not change the gloves or sanitize her hands. The DA was observed walking around the kitchen and then proceeded to stack napkins. On 12/15/22 at 8:14 AM, an interview with the Dietary Manager (DM) was conducted. The DM stated that during dining, staff were expected to take off gloves and sanitize their hands when they walked into the kitchen. The DM stated that when gloves were being used in the kitchen, staff were expected to remove the gloves and sanitize or wash their hands before leaving the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. One 12/13/22 at 8:18 AM, an interview with resident 15 was conducted. Resident 15 stated that he had an itchy rash that was bothering him. Resident 15 stated that the rash was on his legs and started to spread to his back and torso. Resident 15 stated that he had told staff about the rash and requested to see a doctor, but staff told him that he did not have a rash. Resident 15 stated that the rash was really itchy and he stated that he sometimes bled due to scratching. On 12/14/22, resident 15's medical record reviewed. A Nurses Note dated 11/9/22 at 2:21 AM, stated, [Resident 15] called staff in his room states he needs to see a medical professional because the rash that is on his leg has spread to his back. RN [Registered Nurse] assessed his back and hold him he does not have a rash on his back. He [resident 15] states it itches and there are bumps on his back. [Resident 15] was told he has random red bumps on his back that look like acne and not a rash. [Resident 15] then states he has it on his abdomen and his belly button, RN told him there is nothing on his abdomen, chest, legs, or belly button, [Resident 15] became upset with the RN and started scratching his abdomen and back yelling it itches. He then insists that the rash has spread. [Resident 15] was told there is not a doctor available at 2:20 [AM] in the morning. Staff left his room and left his door open [resident 15] then yelled 'shut my damn door.' RN went back in his room and told him he is not to yell that other people are trying to sleep. [Resident 15] was reminded he is supposed to leave his door open and insisted it be shut. A review of resident 15's physician's orders was conducted. Resident 15 did not have any medications or physician's orders to treat symptoms of a rash. On 12/15/22 at 8:21 AM, an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA 2 stated that she recalled resident 15 complaining about a rash. CNA 2 stated she was not sure if the nurses contacted the doctor about the itchy rash. On 12/15/22 at 9:59 AM, a follow up interview was conducted with resident 15. Resident 15 stated that he had told staff multiple times about his legs being itchy and he wished to speak with a doctor about the issue. An observation of resident 15's right leg was made. Resident 15's right leg had a small amount of blood on it. Resident 15 stated that his leg was bleeding due to scratching it. On 12/15/22 at 10:04 AM, an interview with the ADON was conducted. The ADON stated that she worked with resident 15 twice a week and she did not recall resident 15 mentioning a rash. The ADON stated she was unaware of the nurses note dated 11/9/22 at 2:21 AM, which stated that resident 15 was complaining of a rash. The ADON stated that nurses typically pass that information onto the next shift or inform the doctor. On 12/15/22 at 10:55 AM, an interview with the Medical Director (MD) was conducted. The MD stated that he did not recall any staff member informing him about resident 15 having a rash. On 12/15/22 at 12:37 PM, an physician's order was placed for resident 15 that stated, Dry skin (bilateral legs and thighs): Clean with wet wipes, pat dry. Apply A&D Ointment to affected areas BID. Every shift for dry skin AND as needed for relief of dry itchy skin. Apply PRN every 6 hrs [hours]. Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 3 out of 20 sampled residents, a resident with orders to follow up with the Orthopedic Surgeon two weeks after discharge from the hospital did not have a follow up and the surgical staples were not removed until four weeks after discharge from the hospital. A resident with a nephrostomy tube did not receive wound care as ordered by the Physician Assistant (PA) professional wound specialist and a resident with a rash and itchy skin was not treated. Resident identifiers: 12, 15, and 80. Findings included: 1. Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left artificial hip joint, acute respiratory failure, moderate protein-calorie malnutrition, difficulty in walking, benign prostatic hyperplasia, obstructive and reflux uropathy, hypertension, dementia, and acute kidney failure. Resident 80's medical record was reviewed on 12/13/22. On 10/16/22 at 1:34 PM, a Fall Note documented Resident found on floor of his room at 1045 [10:45 PM]. He came to rest on his left side. Staff assessed him and found a skin tear on his left elbow. Stopped the bleeding with direct pressure. He was then assisted to his wheelchair. We then cleaned and dressed the skin tear. He then was assisted to the nurses station so he could be monitored and neuro [neurological] checks made. Step daughter contacted and [name of primary care physician removed] was notified of citation. He was able to transfer to the toilet at 1200 [12:00 PM] when he would not weight bear on the rightleg [sic]. Palpated right femur and found a bump proximal to hip socket. [Name of primary care physician removed] was then called and he wanted him checked out at the ER [Emergency Room]. Non emergency transport was called. Transported at 1326 [1:36 PM] to the ER. On 10/16/22 at 10:08 PM, a Nurses Note documented Called the hospital for update. Resident has a broken L [left] femur. Staying over night at the hospital. On 10/19/22, the Hospital History/Physical And Discharge Summary documented under the Physician Orders section FOLLOW-UP APPT [appointment] w/pcp [with primary care physician] 3-5 days. [Name of Orthopedic Surgeon removed] in 2 weeks. On 10/20/22, a physician's order documented Daily dressing change of surgical incision until dry. Clean using wound cleanser, apply sterile border gauze. one time a day. On 10/21/22 at 5:46 PM, a Nurses Note documented changed dressings to hips bilaterally. incisions show no s/s [signs or symptoms] of infection. staples still in place. states pain 4/10. no other needs at this time. call light in reach. On 11/1/22 at 2:19 PM, a Nurses Note documented Resident admitted for left hip repair and orthopedic aftercare. Surgical incisions healing. No s/s of infection. Wound cleaned,dried and dressed. Pain medications and repositioning help to relieve pain. On 11/2/22 at 10:12 AM, a Nurses Note documented Resident comes to us with left hip repair and orthopedic aftercare. Compliant with medications and cares. Wounds cleaned, dried and dressed. NO signs of infection. On 11/6/22 at 2:18 AM, a Fall Note documented Resident stated that his left leg was hurting. Surgical wound inspected, intact without redness. Resident was transferred to his wheelchair and back to his bed. On 11/16/22 at 12:37 PM, a Nurses Note documented Resident was picked up by a facility transport driver at 1145 [11:45 AM]. Wheeled to the car in wheelchair. He was helped into the vehicle. Paperwork signed. [Note: Resident 80 transferred to another Long Term Care Facility.] The notes from the Long Term Care Facility that resident 80 transferred to were reviewed. The notes included, but were not limited to, the following: a. On 11/17/22 at 10:02 AM, a Category: Telephone Order documented Called [name of Orthopedic Surgeon removed] office in price, he is the surgeon who performed residents surgery on 10/17/22. Spoke with [name removed] (his nurse) resident has not had a follow up since surgery. Let her know that staples are still in place to all 3 incisions. She said the staples should have already been removed by now. Received new order: remove staples today. b. On 11/17/22 at 12:31 PM, a Category: Medication, Treatment, Telephone Order documented Met with [name of physician removed] to review plan of care, discussed redness to left anterior foot, pressure injuries to bilateral feet, staples still in place upon arrival to bilateral hips from surgery in October, has not had ortho [orthopedic] follow up since surgery. Informed him of follow up appointment made with [name of physician removed]. New orders received: Mupirocin ointment apply to wounds on feet BID [twice daily], D/C [discontinue] Staples, . Informed daughter and resident of new orders, they agree with plan of care. c. On 11/17/22 at 3:38 PM, a progress note documented Assisted resident to bed, provided privacy to remove stapled [sic] to R [right] hip and L hip incisions as ordered by physician. 5 staples removed from R hip. 7 staples removed from each surgical site on L hip. Resident tolerated well. No complaints of pain. No complications noted. Applied bacitracin to all sites and applied dressings preventatively. Resident positioned for comfort, call light within reach and bed alarm in place. Resident denies any needs at this time. Implemented treatment to watch sites. On 12/13/22 at 3:42 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the facility did not have any notes because resident 80 did not see the Orthopedic Surgeon prior to discharging to another Long Term Care Facility. The RNC stated resident 80 was scheduled to see the Orthopedic Surgeon on 11/21/22. The RNC stated that she had called the Orthopedic Surgeons office to find out when resident 80's appointment was scheduled. The RNC stated resident 80 discharged from the facility on the 11/16/22. The RNC stated that the Business Office Manager scheduled the resident appointments and was usually unable to get the residents in within the two week time frame that the hospital wanted. The RNC stated that the Administrator in Training would scan the hospital discharge orders into the resident's medical record and would give the packet to the Director of Nursing (DON). On 12/13/22 at 3:54 PM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that the DON would receive the resident admission packet from the hospital and within the packet was the residents appointments. The BOM stated the DON would make a copy of those appointments and bring them to her to schedule the appointments. The BOM stated a new resident would require a follow up with their Primary Care Physician (PCP) within 7 to 10 days after admission to the facility. The BOM stated that some surgeons and PCP were harder to get into than others. The BOM stated that surgeons were usually booked out three weeks. The BOM stated she had called the Orthopedic Surgeon for resident 80 and the earliest they could get him in was four weeks after resident 80 readmitted to the facility from the hospital. The BOM stated resident 80 had discharged from the facility prior to the appointment. The BOM stated that she would let the surgeon know what the hospital orders were. The BOM stated that resident 80's appointment was on 11/21/22, and that was the earliest the Orthopedic Surgeon could get resident 80 in. The BOM stated she did not make a progress note regarding the appointment but had wrote it on a post-it note. The BOM stated that the offices would also call if an opening happened but that was rare. The BOM stated the DON would make the referrals to the house doctor. On 12/14/22 at 8:46 AM, an interview was conducted with the DON at another Long Term Care Facility. The DON stated that resident 80's surgical staples were removed at their facility. The DON stated that resident 80 was seen by the local Orthopedic Surgeon for a follow up on the Monday after admission. The DON stated resident 80 had not had a follow up since his surgery in October 2022. On 12/14/22 at 2:14 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the Orthopedic Surgeon could not get resident 80 in for an appointment within the two week period. The ADON stated that the facility staff could remove resident 80's staples if they got a physician's order to remove the staples. The ADON stated when a resident was readmitted to the facility from the hospital the orders were input into the medical record and the admission paperwork would be resigned. The ADON stated that the DON would go through the orders again and would input the orders and the physician visits. The DON would them give the physician visits to the BOM to schedule. The ADON stated if the resident was suppose to be seen within two weeks after discharge from the hospital she probably would have called and asked the Orthopedic Surgeon what they would have liked them to do. The ADON stated that she would have been able to remove the staples if there was a physician's order. On 12/14/22 at 2:52 PM, an interview was conducted with the RNC. The RNC stated she would have had a discussion with the Orthopedic Surgeon if he was unable to get the resident in for the two week follow up. The RNC stated she would have put in the physician's order and had the facility staff remove the staples if the Orthopedic Surgeon agreed and then the Orthopedic Surgeon would followup at the scheduled appointment. The RNC stated that resident 80's PCP did not see resident 80 within the three to five days after discharge from the hospital as ordered. The RNC stated that the PCP signed the admission orders but did not have a visit note. 2. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encounter for surgical aftercare following surgery on the genitourinary system, hydronephrosis with ureteral stricture, calculus of kidney, type 2 diabetes mellitus, sepsis due to Escherichia Coli, atrial fibrillation, hypertension, acute kidney failure, pain, and anxiety disorder. On 12/12/22 at 2:41 PM, an interview was conducted with resident 12. Resident 12 stated that her nephrostomy tube was not connected to a bag and her down drain Foley catheter came out. Resident 12 stated that the nephrostomy tube was not connected to anything and she did not know if it was draining. Resident 12 stated that her nephrostomy was infected. Resident 12's medical record was reviewed on 12/14/22. On 11/1/22 at 8:01 PM, a Nurses Note documented resident admitted to facility for PT [physical therapy]/OT [occupational therapy] strength training and medication management with dx [diagnosis] of surgical aftercare following surgery on the genitourinary system. she has a Foley catheter that is draining clear yellow urine, she also has a nephrostomy tube on the left flank that is draining clear yellow urine. On 11/8/22 at 3:26 PM, a Nurses Note documented Dr. [doctor] appointment attended today. orders to exchange left nephrostomy tube. Consult to address infections. May also place new tube on right side. On 11/8/22 at 9:29 PM, a Nurses Note documented . resident had a doctor appointment today and the Foley catheter was removed. resident has a nephrostomy tube on the left side that is putting out very little urine. On 11/12/22 at 9:43 PM, a Nurses Note documented nephrostomy tube has had no output. On 11/20/22 at 10:00 PM, a Nurses Note documented no output from nephrostomy bag for afternoon shift. On 11/21/22 at 6:00 AM, a Nurses Note documented no output for night shift from nephrostomy. On 11/30/22 at 3:03 PM, a Nurses Note documented Placed a call to [name of urology clinic removed] concerning [name of resident 12 removed] nephrostomy. Reported to the FNP [Family Nurse Practitioner] that [name or resident 12 removed] is no longer producing urine from the urostomy. She stated that it will need to be replaced as soon as possible. They will return a call today when they are able to schedule the procedure. On 11/30/22 at 8:15 PM, a Nurses Note documented attempted to flush nephrostomy tube per doctor orders the valve leaked around the base where it connects to the part inserted into her back. DON notified it was not able to be flushed. On 12/6/22 at 8:14 PM, a Nurses Note documented . resident has a nephrostomy tube on the left side that has no output. On 12/8/22 at 3:09 PM, a Nurses Note documented During nephrostomy site dressing change, connection to the bag was found broken. This may be why the bag is no longer collecting. Urology was called to see what they would like to do with the site or if they would like to replace the bag. Waiting a call back. On 12/8/22, a progress note by the PA professional wound specialist documented on the assessment that resident 12 had dermatitis associated with moisture. The wound orders included Remove dressing, cleanse wound with standard wound care protocol, apply the following treatment order: Left Flank: apply nystatin/triamcinolone cream and cover with bordered foam, Change dressing once daily and PRN [as needed] if dislodged. Clinical Notes: 12/8/22: Wound nurse reports patient is non-compliant with treatment and refused showers. Nephrostomy drain will not be removed by surgeon until surrounding skin is clear. Follow up: 1 week. On 12/9/22 at 2:18 AM, a Nurses Note documented padding applied to the sharp hard plastic piece of the nephrostomy tube where the bag had been connected. area cleaned and dressing applied to insertion site. On 12/13/22 at 9:09 PM, a Nurses Note documented . resident has a surgical site on her left flank with a nephrostomy tube coming out but there is no bag attached to the tube. On 12/15/22 at 10:39 AM, an interview was conducted with the PA professional wound specialist and the Wound Nurse. The PA stated that he had seen resident 12 for the first time last week. The PA stated that he was trying to get the infection cleared up so the surgeon would take out resident 12's nephrostomy tube. The Wound Nurse stated that resident 12 had seen the Urologist but was told that they wound not take the nephrostomy tube out until it was healed. The Wound Nurse stated if the wound orders were not on the Treatment Administration Record (TAR) it was because she had not put the orders there yet. The Wound Nurse stated the facility staff were trying to get resident 12 to be more compliant with cares. On 12/15/22 at 10:49 AM, an observation was conducted with the PA professional wound specialist and the Wound Nurse. The Wound Nurse was observed to clean the left flank area on resident 12 with wound cleaner. There were no bandages observed over the nephrostomy tube in the left flank area. The Wound Nurse was observed to apply the nystatin/triamcinolone cream to the left flank area and covered the nephrostomy tube with bordered foam. The PA stated to resident 12 that he wanted to continue with the daily dressing changes. The PA stated to resident 12 that the area looked good and by next week it should be cleared up and the PA would be able to call the Urologist and schedule to get the nephrostomy tube removed. On 12/15/22 at 10:55 AM, a follow up interview was conducted with the Wound Nurse. The Wound Nurse stated that resident 12 had a hard time keeping the bandage on because of where it was placed. The Wound Nurse stated that she could not tell me exactly when the bandage fell off. The Wound Nurse stated that she changed resident 12's dressing on Wednesday. [Note: Resident 12's wound treatment was unable to be verified because the wound orders were not entered onto the TAR in resident 12's medical record.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident was offered an influenza and/or pneumococcal immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, for 3 out of 20 sampled residents, residents that had consented to the pneumococcal immunization did not have documentation that the pneumococcal immunization was provided. In addition, a resident that had consented to the influenza immunization did not have documentation that the influenza immunization was provided. Resident identifiers: 19, 23, and 24. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, altered mental status, and essential hypertension. On 12/12/22, resident 19's medical record was reviewed. A signed pneumococcal immunization consent form dated 7/20/22, was located in resident 19's medical record but both the consent and decline options were marked on the form. No documentation could be found that indicated whether resident 19 had or had not received the pneumococcal immunization. 2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, type 2 diabetes mellitus, unsteadiness on feet, schizophrenia, and acute kidney failure. On 12/12/22, resident 23's medical record was reviewed. A signed pneumococcal immunization consent form dated 10/19/22, was located in resident 23's medical record but no documentation could be found that indicated resident 23 had received the pneumococcal immunization. 3. Resident 24 was admitted to the facility on [DATE] with diagnoses which included pneumonia, chronic obstructive pulmonary disease, hypoxemia, chronic viral hepatitis C, personal history of traumatic brain injury, paranoid schizophrenia, and chronic respiratory failure. On 12/12/22, resident 24's medical record was reviewed. A signed pneumococcal immunization consent form dated 11/4/22, was located in resident 24's medical record but no documentation could be found that indicated resident 24 had received the pneumococcal immunization. A signed influenza immunization consent form dated 11/4/22, was located in resident 24's medical record but no documentation could be found that indicated resident 24 had received the influenza immunization. On 12/13/22 at 8:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the facility held vaccination clinics for the staff and residents who wanted to get vaccinated. CNA 1 stated the facility had just held a flu clinic for anyone who wanted the influenza vaccination. On 12/13/22 at 10:18 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated the facility had a weekly in-service which included education on COVID-19 and the vaccine. The IP stated they had occasional vaccine clinics for residents and staff. The IP stated they just had a influenza vaccination clinic and that a COVID-19 vaccination clinic would be coming up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with the Coronavirus disease of 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 5 out of 20 sampled residents, the facility did not provide the resident or resident representative with education of the benefits and potential risks associated with the COVID-19 vaccination. In addition, the resident's medical record did not include documentation regarding the residents' COVID-19 vaccination refusal or acceptance. Resident identifiers: 14, 15, 19, 23, and 24. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses that included non-ST-elevation myocardial infarction, type 2 diabetes mellitus with hypoglycemia, major depressive disorder, chronic pain syndrome, heart failure, and peripheral autonomic neuropathy. On 12/12/22, resident 14's medical record was reviewed. No documentation was found regarding resident 14's COVID-19 immunization status. No documentation was located that indicated resident 14 or resident 14's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included encounter for orthopedic aftercare, displace trimalleolar fracture of left lower leg, epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, and personal history of traumatic brain injury. On 12/12/22, resident 15's medical record was reviewed. No documentation was found regarding resident 15's COVID-19 immunization status. No documentation was located that indicated resident 15 or resident 15's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 3. Resident 19 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, altered mental status, post COVID-19 condition, and essential hypertension. On 12/12/22, resident 19's medical record was reviewed. No documentation was found regarding resident 19's COVID-19 immunization status. No documentation was located that indicated resident 19 or resident 19's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 4. Resident 23 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, type 2 diabetes mellitus, unsteadiness on feet, schizophrenia, and acute kidney failure. On 12/12/22, resident 23's medical record was reviewed. No documentation was found regarding resident 23's COVID-19 immunization status. No documentation was located that indicated resident 23 or resident 23's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 5. Resident 24 was admitted to the facility on [DATE] with diagnoses which included pneumonia, chronic obstructive pulmonary disease, hypoxemia, chronic viral hepatitis C, personal history of traumatic brain injury, paranoid schizophrenia, and chronic respiratory failure. On 12/12/22, resident 24's medical record was reviewed. No documentation was found regarding resident 24's COVID-19 immunization status. No documentation was located that indicated resident 24 or resident 24's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. On 12/13/22 at 8:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the facility held vaccination clinics for the staff and residents who wanted to get vaccinated. CNA 1 stated the facility had just held a flu clinic for anyone who wanted the influenza vaccination. On 12/13/22 at 10:18 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated the facility had a weekly in-service which included education on COVID-19 and the vaccine. The IP stated they had occasional vaccine clinics for residents and staff. The IP stated they just had a influenza vaccination clinic and that a COVID-19 vaccination clinic would be coming up.

Based on interview and record review, the facility failed to inform residents, resident representatives, and resident families of the occurrence of a single confirmed infection of coronavirus disease of 2019 (COVID-19), or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other by 5:00 PM the next calendar day. Specifically, three facility staff members tested positive for COVID-19 and residents, resident representatives, and resident families were not notified of the outbreaks. Findings included: Review of the Facility COVID Testing - Employee Outbreak tracking log revealed the following: a. On 11/17/22, the Administrator (ADM) tested positive. b. On 11/21/22 Therapy 1 tested positive [Note: The Resident Advocate (RA) tested positive on 10/26/22, the results were not documented on tracking log.] Resident progress notes were reviewed for residents 1, 10, 12, 13, 19, 23, and 24. No documentation was found that indicated residents, resident representatives, or resident families were notified of the COVID-19 outbreaks on 10/26/22 and 11/21/22. The facility's Policies and Procedures for Infection Prevention and Control were reviewed. Under section Interventions for Resident Care when COVID-19 is Confirmed it stated Family Notification: The facility will follow guidance from CDC [Centers for Disease Control and Prevention] and CMS [Centers for Medicare & Medicaid Services] about notifying families and responsible parties about the spread of COVID-19 in the facility: Following the occurrence of a single confirmed infection of COVID-19 OR Three or more residents or staff with new onset of respiratory symptoms occurring within seventy-two hours of each other. This notification should include all efforts made by the facility to manage the confirmed infection or cluster of symptomatic residents/staff. Notification may be made through email, website posting, and/or telephone message by 5pm the next calendar day after a COVID-19 infection is confirmed or a cluster of symptomatic residents/staff is identified. After the initial notification, updates must be provided when there are new confirmed infections or clusters. If no new cases are identified, weekly updates must be provided until the infections are resolved. The facility's website was reviewed. In the COVID-19 Facility Status section, the Coronavirus COVID-19 Update revealed the website was last updated on 8/2/22. The last paragraph stated, No news is good news - so if we haven't updated this statement, it means we haven't had any positive tests or other significant issues regarding COVID-19. On 12/12/22 at 2:22 PM, an interview was conducted with the Administrator in Training (AIT). The AIT stated families were notified when there was a COVID-19 outbreak via a phone call. The AIT stated they also posted the information on the front door. The AIT stated the Director of Nursing (DON) oversaw the phone calling but delegated the task to other staff members. The AIT stated she did not know how notifications were documented but stated the RA or DON would know. On 12/12/22 at 2:37 PM, an interview was conducted with the ADM. The ADM stated he tested positive for COVID-19 on Thursday, November 17, 2022. The ADM stated he went into the building, was tested, then left. The ADM stated he had been in the facility Monday through Wednesday prior to testing positive. The ADM stated he did not consider it an outbreak. The ADM stated he was unsure if the residents and their families were notified that he had COVID-19. The ADM stated when someone tested positive for COVID-19, they tried to determine who that person had been in contact with at the facility and tested those specific individuals. The ADM stated he felt the DON would be better able to answer the questions and proceeded to call her. On 12/12/22 at 2:49 PM, an interview was conducted with the DON via phone. The DON stated that the RA notified resident families via phone when there was a COVID-19 outbreak. The DON stated she was unsure how the RA documented the notification phone calls, as this was a new responsibility for the RA. The DON stated that the ADM left the building the day he tested positive and had not been in the building prior. The DON stated the ADM had been at a conference Monday through Wednesday prior to being tested on Thursday. The DON stated there was a folder with this information in her desk. The DON stated the last resident outbreak was a while ago, probably August. The DON stated the facility sent a resident to the hospital where they got COVID-19 and when they returned to facility, they were still positive for COVID-19. The DON stated the last staff outbreak was before Thanksgiving. The DON stated the staff member tested positive and was sent home. On 12/13/22 at 11:17 AM, an interview was conducted with the RA. The RA stated when there was a COVID-19 outbreak, she was responsible to call all resident families and write a progress note that stated the call was made. The RA stated that no one had tested positive for COVID-19 since she received this assignment so she had not made any notification phone calls yet. The RA stated she was assigned the task in August 2022. The RA stated she came to work on 10/26/22, and was tested for COVID-19. The RA stated the test came back positive for COVID-19. The RA stated she had only been at work for three hours before testing positive. The RA stated she had no idea if anyone notified residents or called resident families. The RA stated the last resident who tested positive for COVID-19 that she recalled was in July.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined for 1 of 19 sample residents, that the resident was not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, a resident was showered during the night shift and was not asked about her preference to shower during the day. Resident identifier: 23. Findings include: Resident 23 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, weakness and tremor. On 5/20/21 at 6:50 AM, resident 23 was observed to have recently braided hair. Resident 23 was interviewed and stated that she needed a nap after her shower early that morning. Resident 23 stated that she tried to remain positive and did not want to complain but she did not want to shower in the middle of the night. Resident 23 stated that she liked to go to bed before 9:00 PM and wanted to shower before going to bed. Resident 23 stated that showering at 4:00 AM was better than not getting a shower, but she did not want to shower when she awakened to go to the bathroom. Resident 23 stated that she did not request to shower between 10:00 PM and 6:00 AM. On 5/20/21, resident 23's electronic medical record was reviewed. Shower records revealed that resident 23 was scheduled to shower on graveyard shift, between 10:00 PM and 6:00 AM. Resident 23's task list was available for the past 30 days. Tasks were completed by the Certified Nursing Assistants (CNAs) and revealed the following dates and times of resident 23's showers, along with vital signs that were taken during graveyard shift: a. On 4/22/21 at 2:15 AM (with vital signs taken at 5:33 AM) b. On 4/26/21 at 5:25 AM (vitals taken at 5:20 AM) c. On 4/27/21 at 11:04 PM (vitals taken at 5:33 AM) d. On 5/4/21 at 3:31 AM (vitals taken at 5:20 AM) e. On 5/5/21 at 11:49 PM f. On 5/8/21 at 4:05 AM g. On 5/11/21 at 12:22 AM h. On 5/12/21 at 11:04 PM i. On 5/17/21 at 11:20 PM (vitals taken at 3:30 AM) j. On 5/20/21 at 12:05 AM On 5/20/21 at 8:40 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 23 was asleep by the time the graveyard shift came on at 10:00 PM. CNA 1 stated that resident 23 would probably be showered in the morning, just before the graveyard CNAs left, between 5:00 AM and 6:00 AM. CNA 1 stated that CNAs on the graveyard shift would shower residents would be between 10:00 PM and 11:00 PM for residents who wanted to stay up late, or between 5:00 AM and 6:00 AM for residents who got up early. CNA 1 stated that she was not aware that resident 23 had requested overnight showers. On 5/20/21 at 9:00 AM, the Director of Nursing (DON) and Corporate Resource Nurse (CRN) were interviewed. The DON stated that resident 23 had not complained to her about shower times. The DON stated that resident 23 took naps during the daytime, so resident 23 would awaken to go to the bathroom in the middle of the night. The DON stated that resident 23 was showered when she awakened. The DON stated that there was no documentation that resident 23 had requested to shower during the graveyard shift. On 5/20/21 at 9:20 AM, a follow-up interview was conducted with resident 23. Resident 23 stated that showering in the middle of the night interrupted her sleep pattern. Resident 23 stated that when she used the restroom overnight, she wanted to go back to bed. Resident 23 stated that she was not asked about her shower preferences by the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for 1 of 19 sample residents, it was determined that the facility did not ensure that the resident's environment remained as free of accident hazards as possible. It was also determined that each resident did not receive adequate supervision and assistance devices to prevent accidents. Specifically, facility staff did not ensure the safety of residents transfers, and neglected to use safety devices to prevent falls. Resident identifier: 11. Findings include: Resident 11 was admitted on [DATE] with diagnoses which included metabolic encephalopathy, muscle weakness, atrial fibrillation, polymyalgia rheumatica, chronic kidney disease, protein malnutrition, transient ischemic attack (TIA), altered mental status, lymphedema, and dementia. On 5/18/21 at approximately 10:20 AM, resident 11 was observed to have a bandage on her left hand. Resident 11 was interviewed and stated that she hurt her hand somehow, but was unsure what happened. On 5/18/21 at approximately 12:00 PM a record review was conducted for resident 11. Resident 11's nursing notes revealed that on 5/17/21 at 8:37 PM, Resident was being assisted from her wheelchair to her recliner by Certified Nurses Assistant (CNA), [CNA 3] when the resident started to loose (sic) her footing she grabbed for her wheelchair and the wheels were not locked causing [resident 11] to fall to the floor landing on her buttock and hitting her head on the arm of the couch. Resident also obtained a skin tear on the back of her left hand during the incident. [Resident 11] was c/o (complaining of) back, pelvis and head pain so ambulance was contacted to transfer her to the hospital. [Resident 11's family] was notified of the situation and her being transferred to the hospital. emergency room Doctor notes from 5/17/21 revealed that the residents CT scan and other tests were within normal limits. Steri-strips were applied to residents left hand and it was bandaged. Resident 11 was discharged from the hospital and sent back to the facility. [Note: On 5/9/21 Resident 11 had a hospital visit. It was noted that during her emergency room visit, Resident 11 had a Computerized Topography (CT) of her head, abdomen and pelvis. In addition, in the CT scan, it was noted by the radiologist that Resident 11 had a compression fracture on her second Lumbar Vertebrae. The Radiologist report on 5/9/21 revealed that the fracture is age indeterminate. Subjectively, this is subacute to chronic. This could have contributed to her pain in her back.] On 5/18/21 at approximately 10:00 AM, an interview was conducted with Registered Nurse 1 (RN 1). RN 1 stated that resident 11 was frequently confused and disoriented. RN 1 stated that resident 11 had a fall on 5/17/21 at 8:37 PM while being assisted with a transfer from her wheelchair to her recliner. RN 1 stated that resident 11 lost her footing and reached out to the wheelchair for balance. Resident 11's wheelchair wheels were not locked, and the resident fell to the floor on her buttocks, hitting her head on the armrest of the recliner. RN 1 stated that resident 11 complained of back, pelvis and head pain and had a skin tear on the back of her left hand. RN 1 stated that an ambulance was contacted, the MD (medical doctor) was notified and family was called. On 5/20/21, at approximately 10:00 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated the proper procedures for transferring a resident from a wheel chair. The DON stated that the staff member should lock the wheels of the wheel chair for the residents safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined for 2 of 19 sample residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a licensed practical nurse (LPN) was observed not properly cleaning equipment and a medication administration device according to policy and best practices. It was also observed that the LPN did not follow infection control procedures in medication administration. Resident identifiers: 9 and 16. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic heart failure, type 2 diabetes, depression, diabetic chronic kidney disease, obesity, hypercholesteremia, atrophy of thyroid, autoimmune anemia, muscle weakness, hypertension, dependence on supplemental oxygen and hypoxemia. Resident 16 was admitted to the facility on [DATE] with diagnoses which included edema, sleep apnea, major depressive disorder, Gastro-Esophogeal Reflux Disease (GERD), pulmonary embolism, osteoporosis, difficulty walking, atrial fibrillation, dependence on supplemental oxygen, anxiety disorder, type 2 diabetes, chronic respiratory failure, hypertension, bipolar disorder, muscle weakness, myofibralgia, heart failure, dyspnea, dysphagia, pruritis, acute sinusitis and weakness. On 5/19/21 at approximately 11:00 AM and on 5/20/21 at approximately 7:00 AM, a licensed practical nurse (LPN) 1 was observed checking resident's blood sugars without cleaning the glucometer between the two resident's glucose testing. The residents were resident 9 and resident 16. On 5/20/21 at approximately 7:00 AM, LPN 1 was observed preparing and dispensing insulin through an insulin pen to resident 9. LPN 1 did not clean the hub with alcohol prior to use, contrary to best practices and manufacturer's directions. The medication was administered to resident 9. On 5/20/21, at approximately 07:00 AM, LPN 1 was observed removing one of resident 16's pills from its packaging with bare hands and placing it on an unclean medication cart top. LPN 1 then picked up the pill with bare hands, and placed it in the pill splitter, then placed one half of the pill in resident 16's pill cup. LPN 1 added the rest of resident 16 pills to the cup. LPN 1 then administered the medications to resident 16. On 5/20/21 at approximately 8:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that nursing staff should not handle medications with bare hands. The DON stated that the glucometer should have been cleaned to meet the facility policy and manufacturer's instructions, and the insulin pen's hub should have been cleaned with an alcohol wipe prior to attaching the needle.

Based on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. The Certified Dietary Manager was also working as the maintenance supervisor and was not working full time in the kitchen, and the kitchen supervisor (KS) was not certified. Findings include: On 5/18/21 at 9:22 AM, the kitchen supervisor (KS) was asked to see the certifications for the kitchen staff. The DM's certificate was issued on 10/13/19. A certificate of membership with the Association of Nutrition and Food Service Professionals (ANFP) was also presented. The KS stated that she completed her food handlers permit on 4/28/21, but had to yet receive her card. The KS had a copy of her food handler's permit to view on her phone. Food handler permits were viewed for the remaining kitchen staff members and all permits were current. On 5/18/21 at approximately 10:30 AM, an interview was conducted with the Dietary Manager (DM). The DM also worked as the facility's maintenance supervisor. The DM stated that there was a corporate dietitian (CD 2) and a consulting dietitian (CD 1). The DM stated that CD 2 approved the menus and got input from the facility. The DM stated that he did not know if the menus were standardized throughout the corporation. The DM also stated that he was not sure if the menus were based on the facility population. The DM stated he had attended the Interdisciplinary Team (IDT) meetings, but that the KS was primarily the person who attended those meetings. The DM stated that the KS also completed the resident assessments. The DM stated that the KS was waiting to take the test to certify as a dietary manager. The DM stated that the KS had been working at the facility for 2 months. On 5/19/21 at 11:17 AM, an interview was conducted with the kitchen supervisor (KS). The KS stated she was a full time employee in the kitchen and spent two days each week performing management duties. The KS stated that she worked as a dietary aide on other days. The KS stated there was an aid and a cook for the AM and PM shifts. The KS stated that she had a background as a CNA and was working on her degree in health care management. The KS stated that she had attended resident council meetings from time to time, when there were complaints about the food. The KS stated she contacted the corporate dietitian (CD 2) about making changes to the menu based on what the residents wanted. The KS stated that she and the Director of Nursing (DON) attended the skin and weight meetings. The KS stated the registered dietitian (RD 1) did not attend those meetings. The KS stated that she had not taken the courses to become a certified dietary manager, and was waiting for CD 2 to give her the OK to start taking the courses. The KS stated that she thought the CD 2 was waiting to be sure that the KS was going to be staying at the facility before arranging the courses. The KS stated the course requires completion within 2 years of starting, but the DM told her she could probably finish it in 6 months if she works hard at it. The KS stated the corporate dietitian came down periodically to oversee the kitchen, but was not regularly at the facility.