**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 1 out of 15 sampled residents the facility did not send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Resident identifier: 13 Findings included: Resident 13 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery and presence of right artificial knee joint. On 3/1/25 at 4:16 PM, a nurses note documented, .Patient discharged AMA [Against Medical Advice] .Patient discharged to home . On 5/28/25 at 10:39 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she or the Business Office Manager (BOM) would be the facility staff that would notify the Ombudsman. The RA stated that she was never trained to notify the Ombudsman when residents were discharged and would only contact the Ombudsman if a discharge was difficult. The RA stated that she did not notify the Ombudsman about resident 13's discharge. On 5/28/25 at 10:56 AM, an interview was conducted with the BOM. The BOM stated that the Ombudsman was not notified of every resident that was discharged from the facility. The BOM stated that she only notified the Ombudsman when she was worried about a resident leaving the facility and had concerns for their safety. The BOM stated she did not notify the Ombudsman regarding resident's 13 discharge. On 5/28/25 at 1:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Ombudsman would be notified about difficult resident discharges by the RA or BOM for residents that the facility was worried may have unresolved issues. The DON stated that the Ombudsman should be notified if a resident discharged AMA. The DON stated that she did not know that the Ombudsman should be notified regarding all resident discharges from the facility. On 5/28/25 at 1:47 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that anytime a resident was discharged from the facility the Ombudsman should be notified. The RNC stated that this should be done usually by a monthly summary with the names of the residents who discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 of 15 sampled residents, the resident assessment did not accurately reflect the resident's status. Specifically, two residents who were using oxygen had assessments stating they were not using oxygen at the facility. Resident identifiers: 2 and 10. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses that included atypical atrial flutter, depression, anxiety disorder, and history of falling. Resident 2's medical record was reviewed between 5/27/25 and 5/29/25. A review of resident 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed under Special Treatments, Procedures and Programs-Oxygen-While a resident: No. Resident 2's physician orders included: a. 2 L (liters) nocturnal oxygen by NC (nasal cannula) at bedtime. b. Change O2 (oxygen) humidifier every month on first Sunday. c. Change nasal cannula and tubing every Sunday, label with name and date every Sunday, every day shift, every Sunday. Resident 2's treatment administration record revealed: a. 2 L oxygen administered at night. b. April: Humidifier changed on April 1, 2025 and May 1, 2025. c. Cannula changed every Sunday. Resident 2's care plan had a focus area The resident has oxygen therapy use prn [as needed] noc [at night] r/t [related to] ineffective gas exchange. Date initiated: 3/21/25. The goal was, The resident will have no s/sx [signs or symptoms] of poor oxygen absorption through the review date. Interventions included providing oxygen as ordered and monitoring for respiratory distress. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy, pneumonia, left bundle branch block, and generalized anxiety disorder. Resident 10's medical record was reviewed between 5/27/25 and 5/29/25. A review of resident 10's quarterly MDS assessment dated [DATE] revealed under Special Treatments, Procedures, and Programs- Oxygen- While a resident: No. Resident 10's physician orders included: a. Notify PCP (primary care physician) for increased oxygen needs and oxygen sats (saturation) < 90%. b. Change O2 humidifier every month on first Sunday. c. Change nasal cannula and tubing every Sunday, label with name and date every Sunday. Resident 10's treatment administration record revealed: a. Resident 10's oxygen was checked twice daily in April and May. b. Nasal cannula was changed every Sunday in the months of April and May. c. A humidifier was not observed on resident 10's oxygen concentrator throughout the survey. On 5/28/25 at 10:27 AM, an interview was conducted with CNA (Certified Nursing Assistant) 1 who stated oxygen tubing was changed every Sunday to make sure the residents had clean tubing. CNA 1 stated a plastic bag was attached to the resident's concentrator to put the cannula and tubing in when the resident was not using it to keep it clean and the concentrators were turned off. CNA 1 stated when the tubing was changed, the date was written on the tubing with a black marker, so staff would know when it was changed. CNA 1 showed the surveyor where the tubing was labeled. On 5/28/25 at 10:55 AM, an interview was conducted with the Director of Nursing (DON) who stated resident 2 and resident 10 both used oxygen at night and occasionally during the day. On 5/29/25 at 9:37 AM, an interview was conducted with the MDS Coordinator who stated he completed the MDS assessments on each resident. The MDS Coordinator stated he used observations of the residents, physician orders, and clinical information when completing the resident assessments. The CMS Coordinator reviewed the MDS assessments with the surveyor and confirmed the assessments for resident 2 and resident 10 were incorrect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 out of 15 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's nursing needs. Specifically, a care plan was not developed to address the resident's oral hygiene care. Resident identifier: 11. Findings included: Resident 11 was admitted to the facility on [DATE] with diagnoses which included other neurological conditions, respiratory failure, and seizure disorder. On 05/27/25 at 12:00 PM, resident 11 was observed in the dining room. Resident 11 was observed to have white buildup on his teeth. Resident 11 stated he brushed his own teeth, had not seen a dentist while in the facility, and had not been to a dentist out of the facility. Resident 11's medical record was reviewed from 5/27/25 through 5/29/25. The minimum data set (MDS) assessmen dated 4/8/25, revealed resident 11 required setup or cleanup assistance with oral hygiene. A care plan dated 10/14/24, revealed staff were to assist with (activities of daily living) and mobility as needed. Some interventions included, Improve ADL (activities of daily living) self-performance, encourage as much independence as possible, provide any adaptive equipment needed to assist patient with obtaining, staff to assist with ADLs and mobility as needed. Certified Nursing Assistant (CNA) documentation from 5/15/25 to 5/27/25, revealed resident 11 had received oral care assistance 8 times in the last 14 days. A review of Resident 11's nursing progress notes from 4/28/25 to 5/28/25 revealed no documented concerns with teeth or gums. On 5/28/25 at 9:09 AM, an interview was conducted with CNA 2. CNA 2 stated staff had tried encouraging resident 11 with brushing teeth. CNA 2 stated staff talked with resident 11's sister to encourage him to brush his teeth. CNA 2 stated before he was admitted to the facility, resident 11's sister encouraged him to take care of his teeth. CNA 2 stated staff reminded resident 11 to brush his teeth daily. CNA 2 stated resident 11 usually responded to morning staff saying he would brush his teeth after dinner. CNA 2 stated staff assisted residents to brush their teeth after showering. CNA 2 stated resident 11 was scheduled as an afternoon shower. CNA 2 stated resident 11 always stated he would brush his teeth later when prompted to brush. CNA 2 stated it was not being passed from shift to shift whether resident 11 completed brushing his teeth. On 5/28/25 at 9:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been developed to address resident 11's need for more assistance with oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 15 sampled residents, the facility did not provide appropriate treatment and services to maintain or improve his ability to carry out the activities of daily living (ADL). Specifically, a resident was observed to have buildup on his teeth and there was no documentation that he was provided oral care routinely. Resident identifier: 11. Findings included: Resident 11 was admitted to the facility on [DATE] with diagnoses which included other neurological conditions, respiratory failure, and seizure disorder. On 05/27/25 at 12:00 PM, Resident 11 was observed in the dining room. Resident 11 was observed to have white buildup on his teeth. Resident 11 stated he brushed his own teeth, had not seen a dentist in the facility, and had not been to a dentist out of the facility. Resident 11's medical record was reviewed from 5/27/25 through 5/29/25. The minimum data set (MDS) assessment dated [DATE], revealed resident 11 required setup or cleanup assistance with oral hygiene. A care plan dated 10/14/24, revealed staff were to assist with ADLs and mobility as needed. Some interventions included, Improve ADL self-performance, encourage as much independence as possible, provide any adaptive equipment needed to assist patient with obtaining, staff to assist with ADLs and mobility as needed. Certified Nursing Assistant (CNA) documentation from 5/15/25 to 5/27/25, revealed resident 11 had received oral care assistance 8 times in the last 14 days. A review of resident 11's nursing progress notes from 4/28/25 to 5/28/25 revealed no documented concerns with teeth or gums. On 5/28/25 at 9:09 AM, an interview was conducted with CNA 2. CNA 2 stated staff had tried encouraging him with brushing teeth. CNA 2 stated staff talked with resident 11's sister to encourage him to brush his teeth. CNA 2 stated before resident 11 was admitted to the facility, the sister encouraged him to take care of his teeth. CNA 2 stated staff reminded resident 11 to brush his teeth daily. CNA 2 stated resident 11 usually responded to morning staff saying he would brush his teeth after dinner. CNA 2 stated staff assisted residents to brush their teeth after showering. CNA 2 stated resident 11 was scheduled as an afternoon shower. CNA 2 stated resident 11 always stated he would brush his teeth later when prompted to brush. CNA 2 stated it was not being passed from shift to shift whether resident 11 was completing his teeth brushing. On 5/28/25 at 9:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNA's instructed resident 11 in the morning to brush his teeth. The DON stated she was not aware of where CNA's document oral hygiene. The DON stated she didn't know if reminders to brush teeth were passed along in shift change to ensure it was getting done in the afternoon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 3 of 15 sampled residents, the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction, and behavioral interventions unless clinically contraindicated in an effort to discontinue the drugs; additionally the facility did not ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days unless clinically contraindicated. Specifically, there was no rationale after 90 days for continued use of a prn anti-anxiety medication, another resident did not have a rationale for continuation of an anti-depressant and anti-anxiety and another resident did not have a gradual dose reduction that was ordered by the physician implemented. Resident identifiers: 2, 7 and 11. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety disorder, muscle weakness, bradycardia and history of falling. Resident 2's medical record was reviewed between 5/27/25 and 5/29/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident 2 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Resident 2's care plan dated 3/18/25 included a focus area, I use an anti-anxiety medication(s) r/t [related to]: Anxiety Disorder. The goal was, I will be free from discomfort or adverse reactions related to anti-anxiety therapy during my stay. Interventions included to administer anti-anxiety medications as ordered by the physician and monitor for side effects. A physician's order dated 12/17/24 and discontinued on 3/16/25 revealed, Ativan Oral Tablet 1 MG (Lorazepam) Give 1 mg by mouth every 4 hours as needed for Anxiety related to GENERALIZED ANXIETY DISORDER (F41.1) for 90 Days. A physician clinic note dated 12/17/24 revealed, .Patient is at [facility] today for evaluation and discussion about agitation that the patient's been having recently .Nursing is concerned about her being more aggressive, yelling more frequently and has been getting Ativan as needed. This medication has been helpful but has just been a couple of times a day .Continue Ativan but actually increase to every 4 hours as needed severe agitation. Again try to use that medication sparingly now that we are adding the citalopram, readdress how this is working at next visit. A current physician order dated 3/16/25 revealed, Ativan Oral Tablet 1 MG [milligram] (Lorazepam) *Controlled Drug*; Give 1 mg by mouth every 4 hours as needed for Anxiety related to GENERALIZED ANXIETY DISORDER for 90 days. On 3/16/25 at 1:57 PM, a Nurses Note revealed New order for continued use per [Physician Name redacted] as follows: Ativan Oral Tablet 1 MG Give 1 mg by mouth every 4 hours as needed for Anxiety related to GENERALIZED ANXIETY DISORDER for 90 days. Continued use date for 90 days set for 6/14/2025. [Note: There was no rational for the continued use of prn Ativan that was ordered on 3/17/25.] Resident 2's March, April, and May 2025 Medication Administration Record revealed Ativan was administered on 3/19/25, 3/21/25, 4/2/25, 4/8/25, 4/15/25, 4/20/25, 4/29/25, 5/6/25, 5/13/25, 5/22/25, 5/23/25, and 5/24/25. On 4/22/25, a quarterly psychotropic medication review revealed a review of Ativan 1 mg Q 4 hours PRN. Resident 2 had 7 verbal episodes of anxiety and 6 episodes of agitation. IDT determination was to maintain the medication regimen, and the physician agreed. On 5/29/25 at 10:59 AM, an interview was conducted with Registered Nurse (RN) 1 who stated the physician usually wrote a prescription for a 14 day PRN medication. RN 1 stated if the medication was still needed after the 14 days the physician would assess the resident and renew the resident for 90 days. On 5/29/25 at 11:08 AM, RN 1 stated she could not find a document or progress note for a continued use of the Ativan from the new physician ordered date of 3/17/25. The Regional Nurse Consultant (RNC) who was also present stated she would ask the Director of Nursing (DON) about it. No additional documentation was provided by the facility with the physician's rationale for the continued use of prn Ativan that was ordered on 3/17/25. 2. Resident 7 was admitted on [DATE] with diagnoses of orthopedic aftercare, diabetes, and anxiety disorder. Resident 7's medical record was reviewed on 5/27/25 to 5/29/25. Resident 7's physician orders revealed the following; a. On 11/15/23, Citalopram Hydrobromide oral tablet 20 MG orally in the morning for dysthymic disorder. The order was discontinued on 10/17/24. On 10/17/24, Citalopram Hydrobromide Oral Tablet 20 MG, give 15 mg orally in the morning related to dysthymic disorder. b. On 11/14/23, Bupropion HCL (hydrochloride) tablet 150 MG give by mouth twice daily related to anxiety. The order was discontinued on 1/17/25. On 1/17/25, Bupropion HCl Oral Tablet 100 MG, Give 100 mg by mouth two times a day related to anxiety disorder. An MDS assessment on 2/27/25 stated the resident was on antidepressant medications. On 11/18/2023 at 3:03 PM, a nurses note revealed, A Physician Rationale for Duplicative Medication: Antidepressant: Patient admitted with orders for Bupropion to manage s/s (signs and symptoms) of anxiety and orders for Citalopram to manage s/s of dysthymic disorder. Patient expresses that both of these medications are working well to minimize the s/s of depression and anxiety. Patient expressed that she would like to continue with this regimen. At this time, patient benefits from duplicative medication: antidepressant (Bupropion, Citalopram). Patient has appropriate dx [diagnosis] (F34.1 Dysthymic Disorder and F41.9 Anxiety Disorder) to merit the appropriate usage of medication. Appropriate paperwork has been completed, awaiting MD response. [Note: There was no information regarding the MD's response located in resident 7's medical record.] On 7/17/24, a psychotropic drug review revealed to maintain Bupropion 150 MG twice daily and Citalopram 20 MG daily with no other documented rationale information. On 10/15/24, a psychotropic drug review revealed to maintain Bupropion at 150 MG. Citalopram was decreased to 15 MG daily. On 1/14/25, a psychotropic drug review revealed Bupropion 150 MG was recommended to decrease to 100 MG twice daily. On 4/22/25 a psychotropic drug review revealed Bupropion 100 MG twice daily and Citalopram 15 MG daily were to maintain with no other documented rationale information. On 6/3/25 at 10:03 AM, a phone interview was conducted with the DON. The DON stated the order for Citalopram had 20 MG and 15 MG was confusing. The DON stated the pharmacy provided a 15 MG dose. The DON stated she did not have any further documentation of a second gradual dose reduction or rationale to not reduce the Citalopram and Bupropion. 3. Resident 11 was admitted to the facility on [DATE] with diagnoses which included other neurological conditions, respiratory failure, and seizure disorder. Resident 11's medical record was reviewed 5/27/25 to 5/29/25. On 9/30/24, resident 11 had an order for Trazadone oral tablet 50 MG (milligrams) orally at bedtime related to insomnia. On 4/22/25, in the psychotropic review meeting, the physician recommended a decrease in Trazodone to 25 MG. On 4/26/25 at 2:49 PM, a nurses note stated, Pt (patient) was reviewed in psychotropic meeting on 4/22/25. They recommend to maintain current Valproic Acid orders. Recommend to decrease Trazodone to 25mg PO (per oral) QHS (every night at bedtime) r/t insomnia. Psychotropic drug review agreed to & signed by [physician's name removed], all changes implemented. N.O. (new order) DC (discharge) Trazodone 50mg PO QHS and start Trazodone 25mg PO QHS r/t insomnia. MAR updated. On 5/29/25, an interview was conducted with the DON who stated the GDR order for Trazodone was not written correctly. The DON stated she wrote the progress note in the medical record but forgot to change the order for the physician to sign.

Based on interview, the facility did not employ a full time Director of Food and Nutrition Services with the required qualifications of Certified Dietary Manager, Certified Food Service Manager or with a degree in food service management or 2 or more years of experience as a director of food and nutrition services. Specifically, the facility's Certified Dietary Manager was employed part time and the full-time Dietary Manager was not yet certified to work as a Dietary Manager. Findings included: On 5/27/25 at 12:42 PM an interview was conducted with the Dietary Manager in Training (DMT) who stated she was the full-time manager but was not certified. The DMT stated she was preparing to take the courses necessary to be certified. The DMT stated the previous Dietary Manager (DM) was working part time and training her. On 5/28/25 at 8:15 AM, an interview was conducted with the DM who stated she was a certified dietary manager and was working 20 hours per week, and sometimes less, but was available by phone all the time. The DM confirmed she was training the DMT and preparing her to take the necessary courses for certification. The DM stated the Corporate Dietitian (CD) completed remote assessments for the facility and visited the facility quarterly for 1 day. The DM stated the CD reviewed the resident charts and documentation, resident assessments, completed kitchen and sanitation audits, meal audits, and addressed resident issues that required the care of a dietitian.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer, walk-in refrigerator and dry food storage room were open to the air. Additionally, food items in the food storage room were past their use by dates. Findings included: On 5/27/25, at 12:42 PM, an initial walk-through of the kitchen was conducted. In the walk-in freezer, a box of bulk frozen peas was open to air. In the dry food storage room, a box of dried mashed potatoes was open to air, a box of baking soda was open to air. A bottle of apple cider vinegar with an open date of 11/13/23 had a use by date of 12/20/24. A container of baking powder had a best used by date of 4/24/25. Two packages of yeast had expiration dates of 12/21/24. On 5/29/25 a second walk-through was conducted in the kitchen. In the walk-in freezer, a box of omelet replacements was open to air, and a box of omelets was open to air. In the dry storage room, a box of baking powder had a best used by date of 4/24/25. A box of dried mashed potatoes was open to air, a large container of Worcestershire sauce had a best used by date of 3/17/25. A container of Maltomeal for [name written on container] had an open date of 6/15/23, and a use by date of January 2025. On 5/29/25 at 12:00 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the Corporate Dietitian (CD) came to the facility quarterly and completed a kitchen audit that included looking in the refrigerator, and dry storage areas. The DM stated the CD provided the DM or the DMT (Dietary Manager in Training) a report with the findings that also was provided to the Administrator and the Director of Nursing. The DM stated the CD's findings were included in the information that kitchen staff were educated about. The DM stated kitchen staff were continuously educated about sanitation and proper food storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/27/25 at 12:05 PM, an observation was made of the lunch meal service in the resident's hallway. The meal cart was centered in the hallway between rooms 109-111. Meals were delivered from that central point. A drink cart was parked next to the meal cart. At 12:06 PM, a tray was delivered to room [ROOM NUMBER]. The resident's meal was delivered with lemonade uncovered. At 12:09 PM, the meal cart was moved to between rooms 117-119. At 12:15 PM, a tray was delivered to room [ROOM NUMBER]. The resident's meal was delivered with milk and juice uncovered. On 5/28/25 at 8:13 AM, a brief observation was made during the breakfast meal service in the resident's hallway. Two trays were observed to be delivered to room [ROOM NUMBER]. The juice on the trays were uncovered. Additionally, the dietary aide left the room and returned with a cup of milk and a cup of coffee that were both uncovered. At 8:17 AM, a tray was delivered to room [ROOM NUMBER] with a pre-packaged container of cold cereal that had been opened and was uncovered. On 5/28/25 at 12:10 PM, an observation was made of the lunch meal service in the resident's hallway between rooms [ROOM NUMBERS]. At 12:15 PM, a tray was delivered to 121 with the soup uncovered. The dietary aide shook a bottle of milk that resulted in water condensate splashing into the soup. At 12:18 PM, a tray was delivered to room [ROOM NUMBER] with the soup uncovered. Milk and peach tea were observed to be uncovered. Based on observation, interview, and record review, it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, during medication pass a staff member was observed to place her bare fingers inside the medication cups prior to administering medications to residents. Additionally, during hallway meal pass, drinks, cold cereal and soup were observed to be transported uncovered to residents. Resident identifiers: 10, 11 and 12. Findings included: 1. On 5/28/25 at 7:15 AM during morning medication pass the following was observed: a. At 7:17 AM, Registered Nurse (RN) 1 was observed to touch the computer keyboard, the computer mouse, and the medication cart keys. RN 1 was observed to then pick up a medication cup and place her bare thumb inside the medication cup. RN 1 was then observed to place resident 12's medications inside the cup. RN 1 was then observed to administer the medications to resident 12. b. At 7:23 AM, RN 1 was observed to pick up a medication cup and place her bare thumb inside the medication cup. RN 1 was then observed to place resident 11's medications inside the cup. RN 1 was then observed to administer the medications to resident 11. c. At 7:41 AM, RN 1 was observed to pick up a medication cup and place her bare thumb inside the medication cup. RN 1 was then observed to place resident 10's medications inside the cup. RN 1 was then observed to administer the medications to resident 10. On 5/28/25 at 8:26 AM, an interview was conducted with RN 1. RN 1 stated that you should never touch the inside of the medication cup before administering medications to residents because it wasn't sanitary. On 5/28/25 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that at no time should a nurse touch the inside of a medication cup with bare hands and if this happened the nurse should use a new medication cup.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 1 out of 17 residents, that the facility did not ensure that the Interdisciplinary Team (IDT) had determined that the resident was safe to self administer medications. Specifically, a resident was not evaluated to determine if they were safe to self administer two inhaler medications. Resident identifier 65. Findings included: Resident 65 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery, artificial hip joint, allergic rhinitis, chronic kidney disease, anxiety disorder, herpes viral infection urogenital system, trochanteric bursitis, hyperlipidemia, hypertension, insomnia, carpal tunnel syndrome, back pain, spondylosis, major depressive disorder, osteoarthritis, rheumatoid arthritis, sicca syndrome, and tinea unguium. On 8/30/21 at 2:55 PM, an interview was conducted with resident 65. An observation was made of two inhalers at the resident's bedside. Resident 65 stated that the inhalers were Albuterol and Breztri. Resident 65 stated that she was self administering both inhalers 2 puffs two times a day, morning and night. The resident stated that she had always administered the medication herself. Review of resident 65's physician orders revealed the following: a. Breztri Aerosphere Aerosol 160-9-4.8 microgram (mcg)/ACT (Actuation) (Budeson-Glycopyrrol-Formoterol), inhale 2 puffs orally two times a day related to allergic rhinitis. The medication was initiated on 8/19/21. b. Albuterol Sulfate HFA (hydrofluoroalkane) Aerosol Solution 108 (90 Base) mcg/ACT, inhale 2 puffs orally at bedtime related to allergic rhinitis. The medication was initiated on 8/19/21. Review of resident 65's August 2021 Medication Administration Record (MAR) documented that the Albuterol was administered 12 times and the Breztri was administered 24 times. Review of resident 65's medical records revealed no documented assessments for self administration of the medications. On 8/31/21 at 12:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if a resident had a medication at bedside to self administer it would be stated in the order. LPN 1 stated that when she wrote an order for Albuterol she wrote those instructions in the order. LPN 1 stated that the medical director was fine with that, and she had a standing house order to include self administration for inhalers. LPN 1 was observed to obtain a list of standing orders from the medical director. The standing orders did not contain orders to add self administer to inhalers, and no standing orders were observed for inhalers. The LPN stated that the MDS Coordinator verified the admission orders. LPN 1 stated that she determined that a resident was safe to self administer a medication based on if they were alert and oriented, could state the medication back, could determine the need for the medication, and could state back how to administer the medication. LPN 1 stated that resident 65 self administered the Breztri, and did two puffs of the medication. LPN 1 stated that when she administered resident 65's morning medications she would ask if she had taken the inhaler. LPN 1 stated that resident 65 had a long established use of the medication. LPN 1 stated she was not aware that resident 65 had two inhalers at the bedside, and that she did not know about the Albuterol because it was due to be administered at bedtime. LPN 1 stated that she documented in the MAR that the medication was administered based on what the resident told her she had done. On 8/31/21 at 12:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that for residents who wanted to self administer medications, such as inhalers, they conducted a quick assessment to ensure that the resident could do it safely. The DON stated that for inhalers they evaluated that the resident was holding the inhaler correctly, if they were rinsing their mouth out afterwards, and if they were administering the appropriate dosage. The DON stated that they did not have a standing order for the nurses to write in the order to self administer the inhaler. The DON stated that the resident would need to be evaluated first to see if they would be able to self administer safely. The DON stated that the self administration evaluation would be documented in the progress notes. The DON stated that the note would document that the resident was evaluated to self administer safely, could demonstrate the safe administration of the medication and for the right reason, and that the resident's cognitive status would be mentioned in the progress note as well. On 8/31/21 at 4:15 PM, resident 65's progress notes documented, Pt (patient) is A (alert) & O (oriented) x 4 (self, situation, time and place) and verbalizes understanding of proper administration of inhalers. Reviewed current orders with pt, specifically about only taking the albuterol at HS (bedtime). Pt verbalized understanding. Okay for pt to self-administer inhalers and keep at bedside. It should be noted that the note was documented after the interview with the DON and 12 days after resident 65's admission. Resident 65 was discharged from the facility the following day on 9/1/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, osteoporosis, history of falling, morbid obesity, and peripheral neuropathy. On 8/31/21 resident 4's medical records were reviewed. On 7/31/2021 at 12:45 PM, resident 4's progress notes documented, A CNA was in changing [resident 4] brief. [Resident 4] rolled off of the bed and landed on her stomach. The CNA came and got me, and I went in to find [resident 4] on the ground in prone postion (sic). she had a (sic) approximately 1 inch scrape on her elbow. [CNA] and I turned [resident 4] over onto her back. Immediately I saw a pool of blood on the floor where her face had been, and saw a large laceration on [resident 4] cheek. I grabbed the closest paper towels and immediately started applying pressure. I then had [CNA] hold pressure while Called (sic) 911 and had EMT's (Emergency Medical Technicians) be alerted to come. Police showed up and EMT's soon after that. The (sic) loaded [resident 4] onto the gurney and took her. An emergency department physician's report dated 7/31/21 at 2:12 PM revealed the following: History of Present Illness: Brought to the emergency department midday on a Saturday for evaluation of a fall with facial laceration. Medical Decision Making/Differential DX (diagnosis): Fall with laceration to face .6 interrupted five-point 0 Ethilon sutures were used to close the wound .The scleral hemorrhage should resolve without undue problem .You do have a lot of bruising involving the right side of your face. There is also a little bit of bleeding involving the right side of your eye. On 8/1/21 at 10:02 PM, resident 4's progress notes documented, Patient C/O (complained of) pain 7/10 to head/R (right) side of face, LLE (left lower extremity), and R back/rib area .Multiple bruises noted to R forearm, L (left) hand, R cheek, R eye, R chin/neck, R elbow, R knee, L knee and anterior calve/shin (sic), R pannus/groin. Scratches noted to abdomen and R groin/pannus. On 8/2/21 at 10:17 PM, resident 4's progress notes documented, .pt (patient) is wanting to increase pain meds as they are not providing her enough relief from pain, will have day nurse notify MD (medical director) .Pt does yell out in pain during repositioning and changing. On 9/1/21 at 11:46 AM, resident 4 was interviewed. Resident 4 stated, I was hurting really bad when I got back from the hospital. Resident 4 stated she was unable to remember specific details, only that she was in a great deal of pain as a result of the fall. On 9/1/21 at 3:30 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that after the fall, resident 4 had an increase in pain. RN 1 stated if pain was new or increased they would call the MD even if it was the middle of the night. RN 1 felt that resident 4's pain was being controlled with her current pain medications so there was no need to notify the MD. On 9/2/21 at 9:13 AM, Licensed Practical Nurse (LPN) 1 was interviewed over the phone. LPN 1 stated that if a resident had new or worsening complaints of pain, nursing staff should notify the MD immediately. LPN 1 stated resident 4's pain was being controlled with her current medication. Resident 4's Medication Administration Record (MAR) for the months of July and August were compared. From July 1st to July 30th resident 4 requested her PRN (as needed) pain medication 75 times and rated her pain as a 6 or higher six of those time times. From July 31 to August 6th, the 7 days following resident 4's return from the hospital, she requested her PRN pain medication 25 times. Resident 4 rated her pain as a 6 or greater eighteen of those times. On 9/02/21 at 11:51 AM, the Director of Nursing (DON) was interviewed. The DON stated that when there was a situation where a resident had a change in condition or the nurse had a serious concern, the medical director should be contacted immediately. Based on interview and record review it was determined, for 2 of 17 sampled residents, that the facility did not immediately consult with the resident's physician and notify when there was a significant change in the resident's status or a need to alter treatment. Specifically, a resident had a fecal impaction that required digital evacuation of the bowel and a resident had increasing complaints of pain after a fall and the physician was not immediately notified. Resident identifier 4 and 12. Findings included: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of acquired absence of right below the knee amputation, sepsis, pneumonia, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, chronic kidney disease, iron deficiency anemia, asthma, hyperkalemia, acute respiratory failure, and congestive heart failure. On 8/31/21 at 9:17 AM, an observation was made of resident 12. Resident 12 was observed from the hallway lying in bed on the left lateral side with their buttocks facing the doorway. Resident 12 was observed wiping his buttocks with cleansing wipes. The buttocks was partially covered by a blanket but was exposed during wiping. The resident was observed to be providing self toileting cares from the hallway. The resident could be heard grunting and exclaimed, oh my God! The resident was observed attempting to dig stool out of his anus with a wet wipe. Resident 12 was observed cleaning stool from his fingers and hands with a wet wipe. On 8/31/21 at 9:24 AM, the Social Service Worker (SSW) was observed to enter resident 12's room and stated can I pull up your blanket or help you out. The door was closed behind the SSW. On 8/31/21 at 9:29 AM, Certified Nurse Assistant (CNA) 4 was observed to enter resident 12's room and asked how can I help you sir. The door was closed behind the CNA. On 8/31/21 at 9:57 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 12 had a fecal impaction. LPN 1 stated she assisted the resident with alleviating the fecal impaction by digital removal of the stool and then the resident was able to pass a large bowel movement. LPN 1 stated that the resident was then provided a shower. On 8/31/21 resident 12's medical records were reviewed. On 8/31/2021 at 2:42 PM, resident 12's progress notes documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. Patient has constipation. Patient denies nausea. Patient denies vomiting. Pt initially constipated but did have a xl (extra large) soft BM (bowel movement). The note was authored by LPN 1. No documentation could be found that the physician was notified of the fecal impaction with digital evacuation of the bowel. Review of resident 12's care plan for altered bowel elimination/incontinence documented check marks next to Senna as ordered, Milk of Magnesia (MOM) as ordered, and Dulcolax as ordered. Goals were that the patient was to have regular bowel movements (BM) and be free from odor and skin irritation on a daily basis. Interventions were to monitor and record BM's in plan of care, medications as ordered, monitor bowel sounds, and weekly and as needed skin evaluations. The care plan was initiated was on 8/11/21. On 9/01/21 at 3:45 PM an interview was conducted with CNA 4. CNA 4 stated that resident 12 had a BM early yesterday morning, and it was a medium sized hard stool rock hard, and was described as the size of a meatball. CNA 4 stated that she entered resident 12's room at the time the SSW was present and resident 12 had a second hard stool that was approximately the same size as the previously one earlier in the morning. CNA 4 described it as a medium hard stool. The CNA stated that at this point she assisted the resident up to the shower. CNA 4 stated that while in the shower resident 12 complained of pain, and initially she thought he was sitting incorrectly. CNA 4 stated she looked for a hemorrhoid, but could not see any. CNA 4 stated that she visualized resident 12's anus as impacted with a BM. CNA 4 stated that she ran warm water over it in an attempt to assist with evacuation of the BM, but it did not work. CNA 4 stated that she then went and got LPN 1, who had to go in and help the resident. CNA 4 stated that LPN 1 assisted with a digital evacuation of the BM. On 9/02/21 at 8:23 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that if a resident was complaining of constipation or if a CNA reported a hard stool she would verify that the resident was constipated prior to administering any medications. The MDS Coordinator stated that if a resident was impacted and a digital evacuation was done it would be reported to the physician. The MDS Coordinator stated that it would be documented in the progress notes along with any new orders that were given by the physician. On 9/02/21 at 8:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident were to have hard stool and become impacted the physician should be notified. The DON stated that the physician should be notified if the nurse had to do a digital evacuation of the bowel, and it should be documented under progress notes along with the notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 17 sampled residents, that the facility did not ensure that the Minimum Data Set (MDS) data was transmitted within 14 days after the resident's assessment was completed. Specifically, a resident was discharged from the facility and the MDS data was not transmitted to the Centers for Medicare and Medicaid Services System for greater than 120 days. Resident identifier 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of left humerus, laceration of scalp, major depressive disorder, anxiety disorder, functional urinary incontinence, anemia, osteoarthritis, cataract, low back pain, hypertension, and morbid obesity. Resident 1 was discharged from the facility on 4/24/21. Review of resident 1's MDS Assessments revealed no documentation of a discharge assessment. On 9/01/21 at 11:06 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the MDS assessments for entry and death were due 14 days after the event. The MDS Coordinator stated that all other MDS assessment must be submitted within 14 days of the MDS completion date. The MDS Coordinator stated that she did not do a discharge assessment on resident 1 and she was discharged from the facility on 4/24/21. The MDS Coordinator stated she should have completed the discharge assessment 14 days after the date of discharge. The MDS Coordinator stated that she had a spread sheet that she tracked the resident admission and discharge date s. The MDS Coordinator stated she was not sure what happened with resident 1 and why it was overlooked. The MDS Coordinator stated that she reviewed the tracking logs daily. The MDS Coordinator also stated that in the monthly quality assessment meeting they conducted a triple check to see if there was a discharge still open and pending, but because it was towards the end of the month it must have slipped through. The MDS Coordinator stated that she would go back now and look at resident 1's information and submit the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 17 sampled residents, that 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, a resident went 5 days without a bowel movement with no interventions and a resident suffered a fall and did not get x-rays for 5 days. Resident identifiers: 4 and 12. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, osteoporosis, history of falling, morbid obesity, and peripheral neuropathy. On 8/31/21 resident 4's medical records were reviewed. On 7/31/2021 at 12:45 PM, resident 4's progress notes documented, a CNA (Certified Nursing Assistant) was in changing [resident 4] brief. [Resident 4] rolled off of the bed and landed on her stomach. The CNA came and got me, and I went in to find [resident 4] on the ground in prone postion (sic). she had a (sic) approximately 1 inch scrape on her elbow. [CNA] and I turned [resident 4] over onto her back. Immediately I saw a pool of blood on the floor where her face had been, and saw a large laceration on [resident 4] cheek. I grabbed the closest paper towels and immediately started applying pressure. I then had [CNA] hold pressure while Called (sic) 911 and had EMT's (Emergency Medical Technicians) be alerted to come. Police showed up and EMT's soon after that. The (sic) loaded [resident 4] onto the gurney and took her. An emergency department physician's report dated 7/31/21 at 2:12 PM revealed the following: History of Present Illness: Brought to the emergency department midday on a Saturday for evaluation of a fall with facial laceration. Medical Decision Making/Differential DX (diagnosis): Fall with laceration to face .6 interrupted five-point 0 Ethilon sutures were used to close the wound .The scleral hemorrhage should resolve without undue problem .You do have a lot of bruising involving the right side of your face. There is also a little bit of bleeding involving the right side of your eye. A review of nursing progress notes revealed the following: a. 8/1/21 at 10:02 PM. Patient C/O (complains of) pain 7/10 to head/R (right) side of face, LLE (lower left extremity), and R back/rib area .Multiple bruises noted to R forearm, L (left) hand, R cheek, R eye, R chin/neck, R elbow, R knee, L knee and anterior calve/shin (sic), R pannus/groin. Scratches noted to abdomen and R groin/pannus. b. 8/2/21 at 7:38 AM. Contacted [medical director], requested orders CT (computerized tomography) of head and x-ray of ribs .awaiting MD (Medical Director) reply. c. 8/2/21 at 5:34 PM. Have monitored pt closely while awaiting MD reply to request for CT/x-rays . Pt (patient) does c/o (complain of) being stiff, sore, and bruised from fall .Awaiting MD reply. d. 8/2/21 at 10:17 PM. Continue to await MD reply for request for CT and x-rays that were requested by day nurse . pt is wanting to increase pain meds as they are not providing her enough relief from pain .Pt does yell out in pain during repositioning and changing. e. 8/3/21 at 4:42 PM. Have continued awaiting MD reply for request for imaging for pt no reply as of yet. f. 8/4/21 at 11:17 AM. [MD] okay with head CT and x-rays of R rib and BLEs (bi-lateral extremities). Called [local hospital] imaging to schedule appt. X-ray has not yet received orders and hospital will not schedule imaging without receiving the MD order. Will try again later. h. 8/5/21 at 9:42 AM. CT scheduled for tomorrow at 1330. X-rays to be completed at this time as well. i. 8/6/21 at 12:35 PM. Resident has a CT scan this afternoon. j. 8/6/21 at 4:07 PM. [MD] stated that there were no trauma findings from the x-rays and CT. Review of the diagnostic lab results revealed that the CT scan of the brain was obtained on 8/6/21 at 1:44 PM and the X-ray of the rib was obtained on 8/6/21 at 2:50 PM. It was noted that the x-ray and CT scan occurred 5 days after resident 4's initial complaints of pain. It was also noted that it took the MD two additional days to send the order to the local hospital before the resident could have the tests completed. On 9/1/21 at 3:30 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that the MD will respond to their texts anywhere from 30 seconds to a few minutes. RN 1 stated, We can always call him if we need. RN 1 stated that there were no alternative contacts in case the MD failed to respond in a timely manner. RN 1 stated she was not sure why resident 4's CT scan and x-rays took 5 days. RN 1 stated at night resident 4 had complained of pain and RN 1 had texted the Doctor. RN 1 could not remember if it was the night of the 31'st or the morning of the 1'st. On 9/02/21 at 9:13 AM, Licensed Practical Nurse (LPN) 1 was interviewed over the phone. LPN 1 stated it takes anywhere from a few minutes to a few hours for the MD to reply to texts or calls. If the MD failed to reply in a timely manner, LPN 1 stated she would continue calling. When asked if she was working during the time there was a delay in getting resident 4's x-rays and CT scan, LPN 1 stated, Yeah, I remember working one day and trying to get ahold of the doctor but he never responded. On 9/02/21 at 11:27 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that it depended on where the MD was located at on how long it took for him to respond to the nurses, but rarely was it the next day. The DON stated that she did recall that in this instance it took the MD a day to respond to the nurse's calls, I remember it was the next day. The DON stated that she did not know why it took an additional 2 days to obtain the CT and x-ray after the MD ordered them. On 9/2/21 at 11:51 AM, the DON was interviewed. The DON was asked when staff have potentially serious concerns and are unable to get ahold of the MD, what options do they have? The DON stated, We can always send them to the emergency room. When asked about resident 4, and if nursing staff should have sent her to the emergency room, the DON stated, If she had continued to complain of head pain we would have sent her out but she stopped complaining of head pain. 2. Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of acquired absence of right below the knee amputation, sepsis, pneumonia, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, chronic kidney disease, iron deficiency anemia, asthma, hyperkalemia, acute respiratory failure, and congestive heart failure. On 8/31/21 at 9:17 AM, an observation was made of resident 12. Resident 12 was observed from the hallway lying in bed on the left lateral side with their buttocks facing the doorway. Resident 12 was observed wiping his buttocks with cleansing wipes. The buttocks was partially covered by a blanket but was exposed during wiping. The resident was observed to be providing self toileting cares from the hallway. The resident could be heard grunting and exclaimed, oh my God! The resident was observed attempting to dig stool out of his anus with a wet wipe. Resident 12 was observed cleaning stool from his fingers and hands with a wet wipe. On 8/31/21 at 9:24 AM, the Social Service Worker (SSW) was observed to enter resident 12's room and stated can I pull up your blanket or help you out. The door was closed behind the SSW. On 8/31/21 at 9:29 AM, Certified Nurse Assistant (CNA) 4 was observed to enter resident 12's room and asked how can I help you sir. The door was closed behind the CNA. On 8/31/21 at 9:57 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 12 had a fecal impaction. LPN 1 stated she assisted the resident with alleviating the fecal impaction by digital removal of the stool and then the resident was able to pass a large bowel movement (BM). LPN 1 stated that the resident was then provided a shower. On 8/31/21 at 10:21 AM, an interview was conducted with resident 12. Resident 12 stated he had no problems with constipation or diarrhea. On 8/31/21 resident 12's medical records were reviewed. Review of resident 12's physician orders revealed the following: a. Senna Tablet 8.6 milligram (MG) (Sennosides), give 1 tablet by mouth every 24 hours as needed for constipation and give 2 tablet by mouth every 24 hours as needed for constipation. The order was initiated on 8/10/2021. b. Milk of Magnesia (MOM) Suspension 1200 MG/15 milliliter (ML) (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for constipation. The order was initiated on 8/10/2021. c. Bisacodyl Suppository 10 MG, insert 1 suppository rectally every 24 hours as needed for Constipation. The order was initiated on 8/10/2021. d. Ferrous Sulfate Tablet 325 MG, give 1 tablet by mouth one time a day related to iron deficiency anemia. The order was initiated on 8/11/2021. e. Hydrocodone-Acetaminophen (Norco) Tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for pain related to encounter for orthopedic aftercare following surgical amputation. The order was initiated on 8/16/2021. Review of the Nursing 2020 Drug Handbook documented that constipation was a common adverse effect of Hydrocodone and needed to be treated aggressively. Wolters Kluwer. (2020). Nursing 2020 Drug Handbook, p. 766. Review of the Drugs.com website for Ferrous sulfate documented side effects may include constipation. The literature was last updated on July 7, 2021. https://www.drugs.com/ferrous_sulfate.html#side-effects Review of resident 12's August 2021 Medication Administration Record (MAR) revealed the following: a. The Ferrous Sulfate was administered as ordered from 8/12/21 to 8/31/21. b. The Hydrocodone 5-325 mg was administered from 8/11/21 to 8/31/21 multiple times a day with a total of 57 doses administered. c. The Bisacodyl was not documented as administered. d. The MOM was not documented as administered. e. The Senna was not documented as administered. Review of the residents bowel continence for the last 30 days revealed the following: a. On 8/13/21 and 8/14/21 no BM was documented. b. On 8/15/21 a large BM was documented. c. On 8/16/21 and 8/17/21 no BMs were documented. d. On 8/18/21 a medium BM was documented. e. On 8/19/21 no BM was documented. f. On 8/20/21 a medium BM was documented. g. On 8/21/21, 8/22/21, 8/23/21, 8/24/21, and 8/25/21 no BMs were documented. It should be noted that the resident went 5 days without a documented BM and no medications or treatments were documented as administered. h. On 8/26/21 and 8/27/21 three small BMs were documented. i. On 8/28/21 a medium and large BM was documented. j. On 8/29/21 no BM was documented. k. On 8/30/21 a medium BM was documented. l. On 8/31/21 two medium constipated/hard BMs and a large constipated/hard BM was documented. It should be noted that this was the date that the resident was reported to have the fecal impaction that required digital evacuation of the bowel by the licensed nurse. It should be noted that in the past 30 days resident 12 had 11 days without a BM and no treatment or medications were administered. Review of resident 12's progress notes revealed the following: a. On 8/21/2021 at 1:50 PM and at 9:23 PM, the note documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. b. On 8/22/2021 at 11:39 AM and at 9:59 PM, the note documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. c. On 8/23/2021 at 9:32 AM, the note documented, Patient uses Toilet/Commode for elimination. Patient uses pads/briefs for elimination. Patient is continent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. d. On 8/23/2021 at 11:49 PM, the note documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. e. On 8/24/2021 at 3:52 PM, the note documented, Patient uses Toilet/Commode for elimination. Patient uses pads/briefs for elimination. Patient is continent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. f. On 8/24/2021 at 11:55 PM, the note documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. g. On 8/25/2021 at 9:25 AM, the note documented, Patient uses Toilet/Commode for elimination. Patient uses pads/briefs for elimination. Patient is continent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. h. On 8/25/2021 at 11:30 PM, the note documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. No constipation present. Patient denies nausea. Patient denies vomiting. i. On 8/26/2021 at 10:45 AM, the note documented that the patients blood pressure this morning was 98/42, and was rechecked at 80/44. The physician was notified about the hypotension and 500 ML intravenous bolus of Lactated Ringers Solution was ordered. The note stated to continue to monitor the resident's blood pressure. It should be noted that this incident occurred immediately following resident 12's 5 days without a documented BM. j. On 8/31/2021 at 2:42 PM, the note documented, Patient uses pads/briefs for elimination. Patient is incontinent of bowel. Bowel sounds present. No diarrhea present. Patient has constipation. Patient denies nausea. Patient denies vomiting. Pt initially constipated but did have a xl (extra large) soft BM (bowel movement). The note was authored by LPN 1. The note did not document the fecal impaction that required a digital evacuation nor the physician notification of the incident. Review of resident 12's care plan for altered bowel elimination/incontinence documented check marks next to Senna as ordered, Milk of Magnesia as ordered, and Dulcolax as ordered. Goals were that the patient was to have regular bowel movements (BM) and be free from odor and skin irritation on a daily basis. Interventions were to monitor and record BM's in plan of care, medications as ordered, monitor bowel sounds, and weekly and as needed skin evaluations. The care plan was initiated was on 8/11/21. On 9/01/21 at 3:45 PM, an interview was conducted with CNA 4. CNA 4 stated that the resident's dashboard would flag how long it had been since the resident had a BM. CNA 4 stated that the nurses also see this on their computer and they often notified the CNAs if the resident had not had any documented BMs. CNA 4 stated that resident 12 had a BM early yesterday morning, and it was a medium sized hard stool rock hard, and was described as the size of a meatball. CNA 4 stated that she entered resident 12's room at the time the SSW was present and resident 12 had a second hard stool that was approximately the same size as the previously one earlier in the morning. CNA 4 described it as a medium hard stool. The CNA stated that at this point she assisted the resident up to the shower. CNA 4 stated that while in the shower resident 12 complained of pain, and initially she thought he was sitting incorrectly. CNA 4 stated she looked for a hemorrhoid, but could not see any. CNA 4 stated that she visualized resident 12's anus as impacted with a BM. CNA 4 stated that she ran warm water over it in an attempt to assist with evacuation of the BM, but it did not work. CNA 4 stated that she then went and got LPN 1. CNA 4 stated that LPN 1 assisted with a digital evacuation of the BM. CNA 4 stated that the resident had a BM on Saturday, 8/28/21, also. CNA 4 stated that the resident would notify the CNAs if he had an incontinence episode and he also required toileting assistance. The CNA stated that resident 12 would report when he needed assistance. CNA 4 stated that if a resident had not had a BM for 3 days in a row they asked the resident if they wanted any prune juice or a laxative and then she would notify the nurse on shift. The CNA stated that if she did not know the resident's bowel pattern she would verify with the resident when their last BM was. On 9/02/21 at 8:23 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the facility bowel protocol was if a resident had not had a BM in 48 hours then the electronic medical records gave an alert to offer a medication to the resident. The MDS Coordinator stated that the night nurse would look through the alerts and print them off for the following day shift. The MDS Coordinator stated that they did not automatically prompt for her to see when she was looking in the Medication Administration Record, and she did not recall how to look up the alerts. The MDS Coordinator stated that she did not work the floor that often, but that the last two days the night shift nurse had printed the alerts out for her. It should be noted that the MDS Coordinator was working as a floor nurse on 9/1/21 and 9/2/21. The MDS Coordinator stated that if a resident went 5 days without a documented BM that would be a concern. The MDS Coordinator stated that they were able to do a look back on a resident's BM history. The MDS Coordinator stated that if a resident was complaining of constipation or if a CNA reported a hard stool she would verify that the resident was constipated prior to administering any medications. The MDS Coordinator stated that if a resident was impacted she would conduct a review of that residents bowel pattern, and if a digital evacuation was done it would be reported to the physician. The MDS Coordinator stated that it would be documented in the progress notes along with any new orders that were given by the physician. On 9/02/21 at 8:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility bowel protocol was if a resident went 3 days without a BM the nursing staff was to administer an intervention of Miralax, Senna, or MOM. The DON stated if that did not work then a suppository or an enema would be tried next. The DON stated that if a resident were to be consistently receiving pain medications or iron supplements they would look into giving a bowel protocol on a more scheduled basis instead of an as needed order. The DON stated that they would not necessarily start off with a scheduled bowel protocol but would take that into consideration. The DON stated that the nursing staff had the ability to look back on a resident's bowel pattern to review the documented BM. The DON stated that in a small facility they had the ability to know the residents closely and would know if a resident was not pooping really good. The DON stated that the electronic medical records system alerted the nurses if a resident did not have a bowel movement in 3 days or 72 hours. The DON stated that the nurses were to administer an intervention first and then notify the MD that an intervention was administered and would update if it was not successful. The DON stated that if a resident were to have hard stool and become impacted the physician should be notified. The DON stated that the physician should be notified if the nurse had to do a digital evacuation of the bowel, and it should be documented under progress notes along with the notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 17 sampled residents, that the facility did not ensure that a resident with pressure ulcers (PU) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident with a Stage II PU was provided wound care treatment without a documented evaluation and order to treat the wound by the wound care specialist. Additionally, the order entered in the medical records for wound care did not specify the type of treatment to be applied to the wound. Resident identifier 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included encounter for aftercare following surgical amputation, acquired absence of left leg below knee, dependence on renal dialysis, end stage renal disease, congestive heart failure, atrial fibrillation, obstructive sleep apnea, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, post-traumatic stress disorder, morbid obesity, diabetic neuropathy, epilepsy, acquired absence or right leg above knee, hypertension, and rheumatoid arthritis. On 8/31/21 at 8:54 AM, an interview was conducted with resident 2. Resident 2 stated he had a PU on his coccyx, and that he had the PU prior to arriving at the facility. Resident 2 stated that the coccyx wound did not currently have a dressing on it. Resident 2 stated that the wound had a dressing prior to coming to the facility but not since he arrived at the facility. Resident 2 stated that the wound sometimes caused him pain while seated in the wheelchair, but not while seated in the recliner. Resident 2 stated that the wound developed from sitting in his wheelchair too much. The resident stated that was why he was seated in the recliner. Resident 2 stated that at the dialysis center they provided him with extra pillows to sit upon. Resident 2's wheelchair was observed without a cushion inside of it. Resident 2 stated his wheelchair at home had a cushion, but the facility did not provide a cushion for the current chair that was provided by the facility. The resident's bed was observed with a normal mattress on the bed. The resident stated that he had good upper body strength and could transfer himself and reposition independently. On 8/31/21 resident 2's medical records were reviewed. Review of resident 2's physician orders revealed the following: a. Juven two times a day for skin integrity. The order was initiated on 8/31/2021. b. Ferrous Sulfate Tablet 325 milligram (MG), give 1 tablet by mouth one time a day for nutritional supplement. The order was initiated on 8/29/2021. c. Zinc-220 Capsule (Zinc Sulfate), give 1 capsule by mouth one time a day for PU wound healing for 20 Days. The order was initiated on 8/20/2021. d. Vitamin C Tablet (Ascorbic Acid), give 500 mg by mouth one time a day for PU wound healing. The order was initiated on 8/20/2021. e. [NAME]-Vite Tablet (B Complex-C-Folic Acid), give 1 tablet by mouth one time a day related to end stage renal disease. The order was initiated on 8/20/2021. f. Diet - CCHO (Consistent Carbohydrate Diet/Liberal Diabetic) diet, Regular texture, Thin/Regular Liquids consistency. The order was initiated on 8/19/2021. g. Vitamin D (Cholecalciferol) Tablet 1000 UNIT (Cholecalciferol), give 1 tablet by mouth one time a day for supplement. The order was initiated on 8/20/2021. h. Change dressing to Stage 2 PU on coccyx every day shift every 3 day(s) for wound care and as needed for wound care/dressing soiling, coming off. The order was initiated on 8/19/2021. i. May change the left below knee amputation (LBKA) dressing twice weekly, or as needed, with antibiotic, xeroform, cotton cast padding, and stump sock. May use brace as needed to keep BKA protected from injury as needed for wound care and every day shift every Monday and Thursday for wound care. The order was initiated on 8/19/2021. Review of the August 2021 Treatment Administration Record (TAR) revealed that the coccyx wound was documented as changed on Monday, Thursday, and Saturday. The TAR documented that the dressing change was completed on 8/20/21, 8/23/21, 8/26/21, 8/29/21. It should be noted that no orders were in place to specify the type of dressing change to be completed. Resident 2's skin Assessments revealed the following: a. On 8/19/21 the admission assessment documented a Stage II PU on the coccyx, with a pup (pressure ulcer prevention) dressing in place. No measurements were documented. b. On 8/24/21 the Skin and Weight assessment documented a sacrum Stage II PU that measured 2.2 centimeters (cm) by (x) 1.1 cm x 0.1 cm. No dressing was documented. c. On 8/27/21 the Weekly Skin check assessment documented a sacrum Stage II PU that measured 2.2 cm x 1.1 cm x 0.1 cm, no odor or drainage was noted. The assessment documented that the resident was seen via telewound today. Review of resident 2's progress notes revealed the following: a. On 8/19/2021 at 4:27 PM, the note documented that the resident was admitted following a LBKA for a non-healing wound. He was alert and oriented x 3 (person, place, situation), and reported he had some occasional forgetfulness from time to time. He was able to transfer from wheelchair to bed with a transfer board and stand by assist. He had a right above the knee amputation (RAKA) that was well healed. He had a stage II PU to sacrum, and pressure dressing to left (L) upper arm from a Peripherally Inserted Central Catheter (PICC) removal earlier today. Incision to L lower leg, otherwise skin intact. b. On 8/20/2021 at 3:54 PM, the note documented Skin/Wound: Changes to skin integrity noted. LBKA dressing in place CDI (clean, dry, intact) stage 2 PU coccyx Patient has current wounds being treated. LBKA and stage 2 PU coccyx Dressing changes as per treatment order. No noted changes to wounds. Application of dressing(s) involving prescription medications and aseptic techniques are required for this patients care. c. On 8/21/2021 at 12:55 PM, the note documented, Skin/Wound: Changes to skin integrity noted. LBKA dressing in place CDI stage 2 PU coccyx Patient has current wounds being treated. LBKA and stage 2 PU coccyxDressing changes as per treatment order. No noted changes to wounds. d. On 8/24/2021 at 2:30 PM, the note documented, [resident 2] was seen via telewound today. The clinician reports area looks good and is showing s/s (signs and symptoms) of healing. new measurements are: 2.2cm x 1.1cm x 0.1cm. no odor or drainage noted. Continue with current tx (treatment) orders. The note was authored by the Director of Nursing (DON). Review of the care plan revealed a focus area for alteration in skin integrity: LBKA and PU stage 2 to sacrum 2.2 x 1.1 x 0.1 cm. Interventions identified included: a. Encourage to turn/reposition/shift position frequently. b. Weekly skin checks. c. Report any skin problems to DON. d. Registered Dietician to consult per protocol. e. Wound care consult per protocol. f. Treatments as ordered per the Medical Director (MD). g. Monitor skin breakdown site(s) for signs and symptoms of infection, and notify the MD as needed. h. Supplements as ordered per the MD. i. Discuss risk/benefits as needed if non-compliant behavior. The care plan also documented a Braden risk protocol score of 15-18, which had the following interventions: frequent turning, maximize mobility, protect heels, manage moisture, nutrition, friction/sheer, and use a pressure-reducing support surface if patient was bed or chair bound. Review of the care plan revealed a focus area for pressure injury for the sacrum. The care plan was identified on 8/19/21. The plan of approach was to investigate the cause, frequent repositioning, air mattress as tolerated (not checked), wheelchair cushion (not checked), dietitian to monitor nutrition, and dressing changes as ordered by physician. The PU protocol initiated documented: zinc, vitamin C, multivitamins, MedPass 60 ml two times a day, every 2 hour turns, and to change dressing to PU every 3 days and as needed. The care plan did not document specific orders for the wound care and dressing changes and was not signed by the physician. On 9/01/21 at 7:31 AM, an interview was conducted with Certified Nurse Assistant (CNA) 4. CNA 4 stated that resident 2 was independent with showers and required only assistance in setting up for the shower. CNA 4 stated that she had not seen the coccyx wound. The CNA was observed to enter resident 2's room and returned immediately. CNA 4 stated upon return that she could not visualize the wound from the shower chair. The MDS Coordinator then stated that the resident had a Stage II PU on the coccyx. On 9/01/21 at 11:33 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the DON had already completed the dressing change on resident 2's coccyx wound today. The MDS Coordinator stated that the resident was getting ready to go to lunch and then depart the facility for dialysis. The MDS Coordinator stated that the DON would often jump in and assist the floor nursing staff. The MDS Coordinator stated that she and the DON were in the process of taking a wound care class to become certified in wound care. The MDS Coordinator stated that the facility did not have a designated wound care nurse, and that they had just started to work with a local wound care provider to do telehealth visits. On 9/01/21 at 11:37 AM, an interview was conducted with the DON. The DON stated that she had changed the resident's coccyx dressing today, and it was changed every 3 days. The DON stated that resident 2 reported that he did not have a dressing on the wound and that was why she put one on it this morning. The DON stated that she was enrolled in the course to become wound certified. The DON stated that they recently started providing telehealth appointments with a wound care provider on 8/24/21 and resident 2 was the first to be seen by this provider. The DON stated that the dressing change to the coccyx was completed by cleansing the area with a derma cleanser, patting the area dry, and then she applied a Aquacel bordered foam adhesive dressing. The DON stated that she obtained wound measurements and the coccyx wound measured 2.1 x 1.0 cm and the wound was now closed. The DON stated that the wound now had more blanchable periwound area. The DON stated that once resident 2 was up in his wheelchair he liked to stay up in the chair. The DON stated that she provided the resident with education on turning and repositioning, and he was able to do this himself. The DON stated that the dressing that she applied was the one that the wound care provider had ordered on 8/24/21. The DON was asked to verify the coccyx wound order in resident 2's TAR. The DON stated that the order was not written clearly. The DON stated that normally the order was written word for word, to cleanse the wound with a specific cleanser, pat dry, apply ordered treatment, and cover with prescribed treatment. The DON stated that according to the order the licensed nursing staff did not know what dressing had been ordered and there was no way to determine what dressing had been completed and documented in the TAR. The DON stated that there was not a written order from the wound care physician. The DON stated that the wound care provider was supposed to figure out how to get the facility a written order, I need to follow up on that. The DON stated that they were supposed to have notes from that visit on 8/24/21, but the provider did not know how to get the facility the notes. The DON confirmed that they did not have any assessments or treatment orders from the wound care provider in resident 2's clinical record. The DON stated that the process with obtaining a new wound care provider had caused some frustration. The DON stated that she followed up on the care plans for the wounds. The DON stated that initially the floor nurse completed the care plans but then she went back and looked at the wounds. The DON stated that any updates to the care plan were hand written in the care plan. The DON stated that the admitting nurse completed the Braden score and inputs it in the care plan and she would follow up on it with the wounds. The DON stated that the causative factors for resident 2's coccyx PU were determined to be pressure and diabetes mellitus. The DON stated that the resident while at home went to his friends house and played games for 4 hours straight. During this time the resident reported being seated in his wheelchair. The DON stated that the resident was non compliant with his diabetes management and treatments. The DON stated that they offered resident 2 an air mattress for the bed and he refused after the first couple of days at the facility. The DON stated that the resident also refused the cushion for the chair and said that it interfered with his transfer ability. The DON stated that the resident arrived on a day that there were 3 admits and there was a good chance that she did not document the refusals. On 9/02/21 at 8:59 AM, a follow up interview was conducted with the DON. The DON stated that she was not able to obtain the wound physician notes. The DON stated that she was going to contact the medical director to see what he would like to do for a wound treatment order since the wound care provider had not provided the order yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 17 sampled residents, that the facility did not ensure that another physician supervised the medical care of residents when their attending physician was unavailable. Specifically, the attending physician did not respond to a resident's change in condition for two days. Resident identifier 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, osteoporosis, history of falling, morbid obesity, and peripheral neuropathy. On 8/31/21 resident 4's medical record was reviewed. On 7/31/2021 at 12:45 PM, resident 4's progress notes documented, CNA (Certified Nursing Assistant) was in changing [resident 4] brief. [Resident 4] rolled off of the bed and landed on her stomach. The CNA came and got me, and I went in to find [resident 4] on the ground in prone postion (sic). she had a approximately 1 inch scrape on her elbow. CNA 1 and I turned [resident 4] over onto her back. Immediately I saw a pool of blood on the floor where her face had been, and saw a large laceration on [resident 4] cheek. I grabbed the closest paper towels and immediately started applying pressure. I then had [CNA] hold pressure while Called (sic) 911 and had EMT's (emergency medical technicians) be alerted to come. Police showed up and EMT's soon after that. The (sic) loaded [resident 4] onto the gurney and took her. An emergency department physician's report dated 7/31/21 at 2:12 PM revealed the following: History of Present Illness: Brought to the emergency department midday on a Saturday for evaluation of a fall with facial laceration. Medical Decision Making/Differential DX (diagnosis): Fall with laceration to face .6 interrupted five-point 0 Ethilon sutures were used to close the wound .The scleral hemorrhage should resolve without undue problem .You do have a lot of bruising involving the right side of your face. There is also a little bit of bleeding involving the right side of your eye. A review of nursing progress notes revealed the following: a. 8/1/21 at 10:02 PM. Patient C/O (complains of) pain 7/10 to head/R (right) side of face, LLE (lower left extremity), and R back/rib area .Multiple bruises noted to R forearm, L (left) hand, R cheek, R eye, R chin/neck, R elbow, R knee, L knee and anterior calve/shin (sic), R pannus/groin. Scratches noted to abdomen and R groin/pannus. a. 8/2/21 at 7:38 AM. Contacted [medical director], requested orders CT (computerized tomography) of head and x-ray of ribs .awaiting MD (Medical Director) reply. c. 8/2/21 at 5:34 PM. Have monitored pt (patient) closely while awaiting MD reply to request for CT/x-rays . Pt does c/o being stiff, sore, and bruised from fall .Awaiting MD reply. d. 8/2/21 at 10:17 PM. Continue to await MD reply for request for CT and x-rays that were requested by day nurse . pt is wanting to increase pain meds as they are not providing her enough relief from pain .Pt does yell out in pain during repositioning and changing. e. 8/3/21 at 4:42 PM. Have continued awaiting MD reply for request for imaging for pt no reply as of yet. f. 8/4/21 at 11:17 AM. [MD] okay with head CT and x-rays of R rib and BLEs (bi-lateral extremities). Called [local hospital] imaging to schedule appt. X-ray has not yet received orders and hospital will not schedule imaging without receiving the MD order. Will try again later. g. 8/6/21 at 4:07 PM. [MD] stated that there were no trauma findings from the x-rays and CT. Review of the diagnostic lab results revealed that the CT scan of the brain was obtained on 8/6/21 at 1:44 PM and the X-ray of the rib was obtained on 8/6/21 at 2:50 PM. It was noted that the x-ray and CT scan occurred 5 days after resident 4's initial complaints of pain. It was also noted that it took the MD two additional days to send the order to the local hospital before the resident could have the tests completed. On 9/1/21 at 3:30 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that the MD will respond to their texts anywhere from 30 seconds to a few minutes. RN 1 stated, We can always call him if we need. RN 1 stated that there were no alternative contacts in case the MD failed to respond in a timely manner. RN 1 stated she was not sure why resident 4's CT scan and x-rays took 5 days. RN 1 stated at night resident 4 had complained of pain and RN 1 had texted the Doctor. RN 1 could not remember if it was the night of the 31'st or the morning of the 1'st. On 9/02/21 at 9:13 AM, Licensed Practical Nurse (LPN) 1 was interviewed over the phone. LPN 1 stated it takes anywhere from a few minutes to a few hours for the MD to reply to texts or calls. If the MD failed to reply in a timely manner, LPN 1 stated she would continue calling. LPN 1 stated she was working during the time there was a delay in getting resident 4's x-rays and CT scan. LPN 1 stated, I remember working one day and trying to get ahold of the doctor but he never responded. On 9/02/21 at 11:27 AM, the Director of Nursing (DON) was interviewed. The DON stated that it depended on where the MD was located at on how long it took for him to respond to the nurses, but rarely was it the next day. The DON stated that she did recall that in this instance it took the MD a day to respond to the nurse's calls. The DON stated that she did not know why it took an additional 2 days to the CT and x-ray after the MD ordered them. On 9/2/21 at 11:51 AM, the DON was interviewed. The DON was asked when staff have potentially serious concerns and were unable to get ahold of the MD, what options were available. The DON stated, There's no one else for the nurses to call; the nurses just need to keep hounding him. The DON stated the nurses always have the option of sending a resident to the emergency room if they were unable to get ahold of the MD. The DON stated if resident 4 had continued to complain of head pain they would have sent her to the emergency room but resident 4 had stopped complaining of head pain so they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, osteoporosis, history of falling, morbid obesity, and peripheral neuropathy. On 8/31/21 resident 4's medical records were reviewed. It was revealed that resident 4 had been taking Duloxetine 60 milligrams (mg) for idiopathic peripheral autonomic neuropathy once a day since 11/04/19. Duloxetine was in the drug class of antidepressants. A Medication Regimen Review (MRR) was completed for the months of June, July, and September. The pharmacist completing the review made no recommendations regarding a Gradual Dose Reduction (GDR) for resident 4's Duloxetine. On 7/12/21 at 2:44 PM, resident 4's progress notes documented, Patient is currently taking Duloxetine 60 mg/HS (at night): other idiopathic peripheral autonomic neuropathy .There are no target behaviors to track. For this reason and because patient is not using medication psychotropically, the medications will not be reviewed in QRTY (quarterly) Psy (psychotropic) Med review. On 9/01/21 at 3:16 PM, the Director of Nursing (DON) was interviewed. The DON stated, We were using it for pain so we didn't think we needed to do a GDR. The DON stated they had never attempted a GDR for resident 4's Duloxetine. Based on interview and record review it was determined, for 2 of 17 sampled residents, that the facility did not ensure that psychotropic drugs were not given unless necessary to treat a specific condition diagnosed and documented in the clinical record and residents who used the psychotropic drugs received a gradual dose reduction and behavioral interventions unless clinically contraindicated. Specifically, a resident was prescribed a psychotropic for insomnia without a diagnosed and documented condition, and a resident was prescribed a psychotropic and did not receive a gradual dose reduction. Resident identifiers: 4 and 64. Findings included: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included fracture of the right femur, aftercare following joint replacement surgery, presence of right artificial hip joint, chronic respiratory failure, allergic rhinitis, major depressive disorder, arthritis, asthma, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, morbid obesity, and back pain. On 8/31/21 resident 64's medical records were reviewed. Review of resident 64's physician orders revealed an order for Doxepin Hydrochloride (HCl) Capsule 100 milligram (MG), give 1 capsule by mouth at bedtime for sleeplessness. The order was initiated on 8/23/2021. Review of the August Medication Administration Record (MAR) revealed that the Doxepin had been administered 9 times from 8/23/21 to 8/31/21. The August Treatment Administration Record (TAR) documented monitoring for number of hours of sleep every day and night shift from 8/23/21 to 8/31/21. On 9/01/21 at 12:26 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the Doxepin was for sleeplessness. The MDS Coordinator stated that resident 64 did not have a diagnosis of insomnia. The MDS Coordinator stated that the Doxepin was an antidepressant but was used as a sleep aide. On 9/01/21 at 12:48 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Doxepin was ordered for sleeplessness, but the order should have stated that it was indicated as a sleep aide. The DON stated the medication was used to treat insomnia as a sleep aide, but that resident 64 did not have a diagnosis of insomnia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 5 sampled facility staff, that the facility did not ensure that testing of all facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of an unvaccinated staff member based on the county positivity rate was not completed for one week out of the four weeks reviewed. Staff identifier: Certified Nurse Assistant (CNA) 5. Findings included: On 8/30/21 at 11:19 AM, an interview was conducted with the Director of Nursing (DON) and the facility Administrator. The DON stated that the county positivity rate was 13.9%, and all staff were universally wearing a surgical face mask and eye protection, either a face shield or goggles, while inside the building. The DON stated that she was the facility Infection Preventionist. The DON stated that they were testing all the unvaccinated staff 2 times a week per the county positivity rate requirements, but this had just increased a week ago. The DON stated that prior to that they were testing one time a week per the county positivity rate. The DON stated they had 19 out 45 staff that were fully vaccinated, or about 42% of staff were fully vaccinated. On 8/30/21 at 1:50 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that people who were not vaccinated were tested 2 times a week. The SSW stated that they received texts from the DON informing them how often they were testing that week at the facility. The DON stated that she was not being tested because she was fully vaccinated. Review of the facility COVID testing logs for August 2021 revealed that (CNA) 5 was tested on [DATE], 8/16/21, 8/23/21, and 8/26/21 with the antigen BinaxNow test. All test results were negative. The testing logs did not document that CNA 5 was tested during the first week of August 2021. Review of the facility staff vaccination log revealed that CNA 5 had declined the COVID-19 vaccine. On 8/31/21 at 9:42 AM, an interview was conducted with the DON. The DON stated that the surveillance log for staff testing did not contain all of the unvaccinated staff because some of the staff were PRN (as needed). For those staff that were PRN and unvaccinated the process was to test them prior to their scheduled shift. On 8/31/21 at 2:23 PM, an interview was conducted with the DON. The DON stated that CNA 5 should have tested the first week of August 2021 and she did not know why she was not tested. The DON reviewed CNA 5's time card and verified that she worked on 8/1/21 and 8/5/21. The DON confirmed that CNA 5 did not test the first week of August 2021 and worked 2 times that week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 6 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, chronic kidney disease, major depressive disorder, and generalized anxiety disorder. On 8/31/21 resident 6's medical record was reviewed. The medical record revealed that on 10/10/20, resident 6 had completed a Provider Order for Life-Sustaining Treatment (POLST) form. The POLST indicated that resident 6 wished to receive full medical treatment in the event of an emergency. The POLST was filled out as follows: a. Attempt to resuscitate. b. Full Treatment. Medical care may include endotracheal intubation, mechanical ventilation, defibrillation/cardioversion, vasopressors, and any other life-sustaining care that is required. The POLST form contained the following instructions: a. The POLST is a Medical Order. b. The POLST must be completed by a medical provider based on patient preferences and medical indications. c. The POLST must be signed by the patient or surrogate decision maker AND by a medical provider to be valid. The POLST instructions listed the following as Medical Providers: Doctors of osteopathic medicine (DO) and doctors of medicine (MD), Physician's Assistant (PA), Advanced Practice Registered Nurse (APRN). The POLST form in resident 6's medical record contained no signature from a medical provider. 6. Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malignant neoplasm of the colon, cerebral infarction, heart failure, and atherosclerotic heart disease of native coronary artery. On 8/31/21 resident 14's medical record was reviewed. The medical record revealed that on 1/29/19, resident 14 had completed a POLST form. The POLST indicated that resident 14 wished to receive comfort measures only in the event of an emergency. The POLST was filled out as follows: a. Do not attempt or continue any resuscitation (DNR) (Allow Natural Death). b. Comfort measures. Medical care may include oral and body hygiene, medication, oxygen, positioning, warmth, and other measures to relieve pain and suffering. The POLST contained the following instructions: a. The POLST is a Medical Order. b. The POLST must be completed by a medical provider based on patient preferences and medical indications. c. The POLST must be signed by the patient or surrogate decision maker AND by a medical provider to be valid. The POLST instructions listed the following as Medical Providers: DO, MD, PA, and APRN. The POLST form in resident 14's medical record contained no signature from a medical provider. The medical record revealed that resident 14 passed away at the facility on 8/1/21. Resident 4's death certificate was signed by nursing staff. The death certificate was not signed by the physician. On 9/2/21 at 10:14 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator confirmed that the folder at the nurse's station contained unsigned orders for the medical director to sign when he came into the facility. The MDS Coordinator stated that the physician did not have set days that he came to the facility and it was usually once every couple of weeks. The folder was observed to contain numerous copies of PT/OT evaluation and treatment orders, POLST forms, care plans, and reports of death. The oldest order identified waiting a physician signature was dated December 2020. On 9/02/21 at 11:27 AM, the Director of Nursing (DON) was interviewed. The DON stated that it depended on where the MD was located as to how frequently he was sending orders into the facility. The DON stated that if the MD was in the clinic he could do it in between patients. The DON stated that the MD did not sign his orders routinely. The DON stated that they use to take the orders to his clinic for signatures but he did not like them at the clinic anymore. The DON stated that if the MD was at the facility she would try to have him sign the orders. The DON stated that most of the time he was at the facility after hours when he was not in clinic, and he did not get them signed. The DON stated that he was not signing a lot of the POLST forms. The DON stated that the care plans were not being signed and the MD did not attend the care plan meetings. The DON stated that she was aware that he was not signing the PT/OT evaluations and treatment plans and death reports, and that they had a large folder at the nurse's station waiting for MD signatures. The DON stated that they did not have any issues with medication and treatment orders being signed because those were faxed directly to him. The DON stated that all the other orders were not faxed to the MD and that was why they were waiting for signatures on them. Based on interview and record review it was determined, for 6 out of 17 sampled residents, that the facility did not ensure that the physician reviewed each residents total program of care, including medications and treatments at each visit; write, sign and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal vaccine. Specifically, residents Physician Orders for Life Sustaining Treatment (POLST) forms, care plans, death reports and physical therapy (PT) and occupational therapy (OT) evaluation and treatment plans were not signed by the medical director (MD). Resident identifiers: 2, 6, 7, 12, 14, and 64. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included encounter for aftercare following surgical amputation, acquired absence of left leg below knee, dependence on renal dialysis, end stage renal disease, congestive heart failure, atrial fibrillation, obstructive sleep apnea, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, post-traumatic stress disorder, morbid obesity, diabetic neuropathy, epilepsy, acquired absence or right leg above knee, hypertension, and rheumatoid arthritis. On 8/31/21 resident 2's medical records were reviewed. Review of resident 2's care plan revealed that the care plan was initiated on 8/19/21 for all identified focus care areas. The care plan was signed by the licensed nurse who initiated the plan on 8/19/21, the floor registered nurse on 8/19/21, the nursing assistant on 8/19/21, the dietary staff representative on 8/20/21 and the resident on 8/19/21. The care plan had an area for the attending physician signature. The care plan was not signed by the physician. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included osteoporosis with fracture of left femur, type 2 diabetes mellitus, acute kidney failure, major depressive disorder, generalized anxiety disorder, hyperlipidemia, cataracts, carpal tunnel, overactive bladder, functional urinary incontinence, back pain, and hypertension. On 9/1/21 resident 7's medical records were reviewed. Review of resident 7's POLST form revealed that the effective date of the order was documented as 7/10/21. The order documented Attempt to resuscitate with Full Treatment: Prolonging life by all medically effective means. Medical care may include endotracheal intubation, mechanical ventilation, defibrillation/cardioversion, vasopressors, and any other life-sustaining care that is required. The order also indicated a trial period of artificial nutrition with feeding tube could be included in the medical care. The order was signed by resident 7, and a facility licensed nursing staff on 7/10/21. The order was not signed by the facility medical provider. 3. Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of acquired absence of right below the knee amputation, sepsis, pneumonia, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, chronic kidney disease, iron deficiency anemia, asthma, hyperkalemia, acute respiratory failure, and congestive heart failure. On 8/31/21 resident 12's medical records were reviewed. Review of resident 12's care plan revealed that the care plan was initiated on 8/11/21 for all identified focus care areas. The care plan was signed by the licensed nurse who initiated the plan on 8/11/21, the floor registered nurse on 8/11/21, the nursing assistant on 8/11/21, the dietary staff representative on 8/11/21, and the resident on 8/11/21. The care plan had an area for the attending physician signature. The care plan was not signed by the physician. Review of resident 12's POLST form revealed that the effective date of the order was not documented. The order documented Attempt to resuscitate with Full Treatment: Prolonging life by all medically effective means. Medical care may include endotracheal intubation, mechanical ventilation, defibrillation/cardioversion, vasopressors, and any other life-sustaining care that is required. The order also indicated a trial period of artificial nutrition with feeding tube could be included in the medical care, and no advance directive was available. The order was signed by resident 12, and by a facility licensed nursing staff on 8/11/21. The order was not signed by the facility medical provider. 4. Resident 64 was admitted to the facility on [DATE] with diagnoses which included fracture of the right femur, aftercare following joint replacement surgery, presence of right artificial hip joint, chronic respiratory failure, allergic rhinitis, major depressive disorder, arthritis, asthma, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, morbid obesity, and back pain. On 8/31/21 resident 64's medical records were reviewed. Review of resident 64's care plan revealed that the care plan was initiated on 8/23/21 for all identified focus care areas. The care plan was signed by the licensed nurse who initiated the plan on 8/23/21, the floor registered nurse on 8/23/21, the nursing assistant on 8/23/21, the dietary staff representative (not dated), and the resident on 8/23/21. The care plan had an area for the attending physician signature. The care plan was not signed by the physician. Review of resident 64's POLST form revealed that the effective date of the order was not documented. The order documented Do not attempt or continue any resuscitation (DNR) (Allow Natural Death) and Comfort Measures: MAXIMIZING comfort and dignity. Medical care may include oral and body hygiene, reasonable efforts to offer food and fluids orally, medication, oxygen, positioning, warmth, and other measures to relieve pain and suffering. Transfer to the hospital only if comfort measures can no longer be managed at the current setting. The order was signed by resident 64, and by a facility licensed nursing staff on 8/23/21. The order was not signed by the facility medical provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, osteoporosis, history of falling, morbid obesity, and peripheral neuropathy. On 8/31/21 resident 4's medical records were reviewed. Resident 4's medical record did not contain any physician progress notes. On 9/2/21 at 10:10 AM, the Minimal Data Set (MDS) Coordinator was interviewed. The MDS Coordinator stated that when the physician visited the facility, there would usually be a nursing progress note documenting the visit. The MDS coordinator stated the physician did not document the visit in the resident's medical record. The MDS Coordinator stated, He'll write his own notes and fax them to us. On 9/2/21 at 11:51 AM the DON was interviewed. The DON stated that when the physician visited the facility she attempted to remind him of orders that require a physician's signature. Based on interview and record review it was determined, for 4 out of 17 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Specifically, resident's medical records did not contain the physician notes, assessments, and orders. Resident identifiers: 2, 4, 7, and 12. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included encounter for aftercare following surgical amputation, acquired absence of left leg below knee, dependence on renal dialysis, end stage renal disease, congestive heart failure, atrial fibrillation, obstructive sleep apnea, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, post-traumatic stress disorder, morbid obesity, diabetic neuropathy, epilepsy, acquired absence or right leg above knee, hypertension, and rheumatoid arthritis. On 8/31/21 resident 2's medical records were reviewed. Review of resident 2's physician orders revealed an order for change dressing to Stage 2 pressure ulcer (PU) on coccyx every day shift every 3 day(s) for wound care AND as needed for wound care/dressing soiling, coming off. The order was initiated on 8/19/2021. No documentation could be found of the physician progress notes, assessment, and wound care orders in resident 2's medical records. On 9/01/21 at 11:33 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the facility did not have a designated wound care nurse, and that they had just started to work with a local wound care provider to do telehealth visits. On 9/01/21 at 11:37 AM, an interview was conducted with the DON. The DON stated that she had changed the resident's coccyx dressing today, and it was changed every 3 days. The DON stated that they recently started providing telehealth appointments with a wound care provider on 8/24/21 and resident 2 was the first to be seen by this provider. The DON stated that the dressing change to the coccyx was completed by cleansing the area with a derma cleanser, patting the area dry, and then she applied a Aquacel bordered foam adhesive dressing. The DON stated that the dressing that she applied was the one that the wound care provider had ordered on 8/24/21. The DON was asked to verify the coccyx wound order. The DON stated that the order was not written clearly. The DON stated that normally the order was written word for word, to cleanse the wound with a specific cleanser, pat dry, apply ordered treatment, and cover with prescribed treatment. The DON stated that according to the order the licensed nursing staff did not know what dressing had been ordered and there was no way to determine what dressing had been completed and documented in the Treatment Administration Record. The DON stated that there was not a written order from the wound care physician. The DON stated that the wound care provider was supposed to figure out how to get the facility a written order, I need to follow up on that. The DON stated that they were supposed to have notes from that visit on 8/24/21, but the provider did not know how to get the facility the notes. The DON confirmed that they did not have any assessments or treatment orders from the wound care provider in resident 2's clinical record. The DON stated that the process with obtaining a new wound care provider had caused some frustration. On 9/02/21 at 8:59 AM, a follow up interview was conducted with the DON. The DON stated that she was not able to obtain the wound physician notes. The DON stated that she was going to contact the medical director to see what he would like to do for a wound treatment order since the wound care provider had not provided the order yet. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included osteoporosis with fracture of left femur, type 2 diabetes mellitus, acute kidney failure, major depressive disorder, generalized anxiety disorder, hyperlipidemia, cataracts, carpal tunnel, overactive bladder, functional urinary incontinence, back pain, and hypertension. On 9/1/21 resident 7's medical records were reviewed. No documentation could be found of the physician progress note, or assessment in resident 7's medical records. 3. Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of acquired absence of right below the knee amputation, sepsis, pneumonia, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, chronic kidney disease, iron deficiency anemia, asthma, hyperkalemia, acute respiratory failure, and congestive heart failure. On 8/31/21 resident 12's medical records were reviewed. On 8/17/2021 4:00 PM, resident 12's progress note documented that the resident was seen by the Medical Director (MD). No documentation could be found of the physician progress note, or assessment in resident 12's medical records. On 9/02/21 at 8:23 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the physician notes would be located in the electronic medical records under documents. The MDS Coordinator stated that was if the physician had sent any of the notes over to the facility, he's not super great at sending them over. Any that he sends over we would scan into the chart. On 9/02/21 at 8:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MD notes and assessments should be located in the miscellaneous section of the resident records. The DON stated maybe his office had not faxed the notes over yet, and that sometimes it took a long time. The DON stated that sometimes they were waiting for the MD to get the notes completed. On 9/02/21 at 11:27 AM, a follow up interview was conducted with the DON. The DON stated she was still waiting for the MD office to send over the MD assessment and visit notes for resident 7 and resident 12. The DON stated that they were completed but not in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, observations were made of staff entering a quarantine room on droplet isolation precautions without donning a N95 mask, staff were observed inside the facility and resident areas without eye protection, and staff were observed wearing their surgical masks down below their nose and mouth. Resident identifier: 2 and 65. Findings included: 08/30/21 11:19 AM, an interview was conducted with the Director of Nursing (DON) and facility Administrator. The DON stated that the county positivity rate was 13.9%, and all staff were universally wearing a surgical face mask and eye protection, either face shield or goggles, while inside the building. The DON stated that they had one room on transmission based precautions (TBP) for a new admission, room [ROOM NUMBER]. The DON stated that the resident in that room, resident 65, was not vaccinated for COVID-19 and was on a 14 day quarantine on droplet/contact precautions. The DON stated that no other residents were on TBP. The DON stated that she was the facility infection preventionist (IP). On 8/30/21 at 12:39 PM, an observation was made of room [ROOM NUMBER] with a personal protective equipment (PPE) cart located outside the door. The PPE cart contained surgical masks, gloves, face shields, disposable gowns, N95 masks, and biohazard bags. Signs posted on the door stated COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel. Preferred PPE - Use N95 or Higher Respirator, face shield or goggles, isolation gown, and gloves. The image showed an Acceptable Alternative PPE - Use Facemask, face shield or goggles, isolation gown and gloves. The image was provided by the Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID-19_PPE_illustrations-p.pdf Additional typed directions were posted next to the image and stated to put on gown, remove regular face mask and discard, donn an N95 mask and form fit, put on face shield, put on gloves, and enter the room. The directions also stated to keep the door closed at all times. No signs were posted that stated droplet/contact precautions. Review of staff training on 6/22/21 documented the agenda as facility COVID rates/efforts, new PPE requirements, donning and doffing PPE, and sanitizing times. The staff training education on 6/22/21 documented admit isolation precautions (14 days) required donning all PPE of a N95 mask, face shield, gown, and gloves. The education stated that any staff member entering a quarantine room must be in PPE. Review of the sign in sheet for the staff training revealed that Licensed Practical Nurse (LPN) 1, Social Service Worker (SSW), and the Therapeutic Recreational Therapist (TRT) were provided the education. On 8/30/21 at 1:50 PM, an interview was conducted with SSW. The SSW stated that staff universally wear a surgical mask and eye protection while inside the facility. The SSW stated that all staff entered through the side entrance by the nurse's station. The SSW stated that the time in clock was located at the nurse's station and had the county positivity rate posted so staff would know if eye protection was required. The SSW stated that eye protection was required when the county positivity rate was greater than 5%. The SSW stated that goggles and surgical face masks were located at the nurses station. On 8/30/21 at 2:25 PM, an observation was made of LPN 1. LPN 1 was observed donning a gown, face shield, and gloves over a surgical mask and then entered room [ROOM NUMBER] on TBP. No hand hygiene was observed prior to entering the room. An immediate interview was conducted with the LPN upon exit of the room. LPN 1 stated that she kept on a surgical mask and did not donn a N95 mask because she had a face shield on. LPN 1 stated that she believed it was acceptable to enter the TBP room with a surgical mask as long as she wore the face shield over it. LPN 1 stated that there was a bin for disposal of the PPE inside the room. LPN 1 stated that she had only been using a surgical mask with a face shield when entering the TBP room. The LPN stated that she discarded the face shield after each use in the TBP room. LPN 1 stated that she performed hand hygiene with alcohol based hand rub prior to exiting the room. On 8/30/21 at 2:36 PM, a follow up interview was conducted with LPN 1. LPN 1 stated that staff entered the facility through the break room back by the DON's office and came to the nurse's station to screen in and obtain their PPE. An observation was made of the time clock located at the nurse's station with the staff screening questionnaire log and a thermometer. Surgical masks were located at the nurses station. On 8/31/21 at 8:00 AM, this surveyor entered the facility and was granted access by Housekeeper (HK) 1. The housekeeper asked if we knew how to do the screening process. The housekeeper was observed with their surgical face mask down below their nose and mouth. On 8/31/21 at 10:24 AM, an observation was made of the SSW exiting room [ROOM NUMBER] on TBP with a surgical mask on. The SSW was observed to doff the surgical mask outside the room and dispose of it in a garbage can located next to the room door and a new surgical mask was obtained from the PPE cart. On 8/31/21 at 12:59 PM, an interview was conducted with the SSW. The SSW stated that she had applied an N95 mask on over her surgical mask prior to entering room [ROOM NUMBER], and the N95 mask was doffed inside the room. The SSW stated that she just put it on over the surgical mask, and pressed it on her face to get a seal with the surgical mask on underneath. The SSW stated that she had been provided training on how to donn and doff PPE, and was last provided training in the summer time. The SSW stated she was not sure if she was provided training on applying a N95 mask over a surgical mask. On 8/31/21 at 1:37 PM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that rooms on precautions required a gown, face shield, mask, and gloves to be worn. HK 1 stated that she wore a surgical mask only when entering these rooms. HK 1 stated that she removed all the PPE outside of the room and disposed of it in the garbage can located just outside the door. HK 1 stated she was provided education on donning and doffing PPE 2 to 3 months ago, right after she started back at the facility in May. HK 1 was observed to have their surgical mask repeatedly fall down below their nose and mouth. HK 1 stated that the surgical mask did not fit properly. HK 1 stated she use to wear a smaller mask, but was told that they did not keep the germs out. On 9/01/21 at 7:51 AM, an observation was made of the dietary manager (DM) entering the facility. The DM was observed wearing a surgical mask. The DM proceeded to the nurse's station and performed hand hygiene, obtained a temperature check, answered the screening questionnaire, and clocked in. The DM was then observed to walk down the resident hallway to the dining room. The DM was not wearing eye protection. On 9/01/21 at 7:53 AM, an observation was made of the TRT entering the facility. The TRT was observed wearing a surgical mask. The TRT proceeded to the nurse's station and performed hand hygiene, obtained a temperature check, answered the screening questionnaire, and clocked in. The TRT walked to the ice machine, obtained a cup and filled it at the sink while speaking to resident 2. The TRT then proceeded down the hallway towards the front of the building and entered the front offices. The TRT was not wearing eye protection. On 9/1/21 at approximately 8:00 AM, an observation was made of a sign posted on the time clock next to the screening station that stated the county positivity rate was 14.4% and eye protection was required. On 9/01/21 at 8:08 AM, an observation was made of the DON and Administrator entering the facility from the back entrance. The Administrator was observed to go directly to the nurse's station and obtained a surgical mask and screened in at the time clock. The Administrator was observed to walk down the hallway to the front office without eye protection. On 9/01/21 at 1:14 PM, an interview was conducted with the DON. The DON stated that all staff clock in and screen at the nurse's station at the beginning of the shift. The DON stated that all staff were required to wear eye protection while in the building. The DON stated that she communicated updates on guidance to staff by email, and by placing flyers next to the screening station and had staff sign that they had read it. In-services were conducted in staff meetings and some were posted by the time clock. The DON stated that donning and doffing education was a posted education at the nurse's station. The DON stated that she tried to have everyone do a return demonstration or a verbal demonstration to ensure competency of the skill. The DON stated that she tracked the nursing staff and highlighted them off a check list when they had completed the competency. The DON stated that it was difficult to track down other department staff to ensure competency of the skills. The DON stated as the IP she was ultimately responsible to ensure every staff member was educated on proper donning and doffing of PPE and the infection control guidance. On 9/02/21 at 8:03 AM, an observation was made of the TRT walking down the south hallway. The TRT was observed wearing a surgical mask without eye protection. Review of the Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes stated under Implement Source Control Measures that health care providers (HCP) working in areas with moderate to substantial community transmission were more likely to encounter asymptomatic or pre-symptomatic residents with SARS-CoV-2 infection. Additionally, HCP should wear a N95 respirator or a well fitting facemask with a nose wire to help the facemask conform to the face, and eye protection should be worn during patient care encounters to ensure that they are protected from exposure to respiratory secretions. The guidance further stated that for new admissions placed in quarantine the HCP should wear an N95 respirator, eye protection, gloves and gowns when caring for these residents. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html

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. Findings included: On 8/30/21 at 12:33 PM, a tour of the facility kitchen was conducted. At that time the facility DM was interviewed. The DM stated, I don't have my CDM (Certified Dietary Manager). The DM stated she was currently enrolled in a CDM program. The DM stated, I've been working here since around February 2019. On 8/31/21 at 12:26 PM, the facility RD was interviewed. The RD stated, I work full-time for [name redacted] Consulting, not the facility. The RD stated that she charted remotely and put in around 4 hours a week working at the facility. On 9/1/21 at 3:15 PM, the Director of Nursing (DON) was interviewed. The DON stated, We knew about that and were expecting the tag. The DON stated that the DM was enrolled in a program but was not certified yet.