**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a baseline care plan for one of 3 residents in the survey sample. Resident #3 (R3) did not have an accurate or timely baseline care plan for immediate care. The Findings Include: Diagnoses for R3 included: Coronary artery disease, end stage renal disease with dialysis (ESRD), hypertension, anxiety, chronic pain, neuropathy, and ischemia. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 10/15/23. R3 was assessed with a cognitive score of 12 out of 15, indicating cognitively intact. Review of R3's clinical record indicated R3 was admitted to the facility on [DATE]. The admission Evaluation was reviewed and documented R3's full assessment was not completed until 10/14/23 (4 days after admission). The baseline care plan (also a part of the admission Evaluation) was reviewed and did not show that a care plan was initiated for code status, pain, skin integrity, and nutrition. Review of admission orders and diagnoses indicated R3 was a full code, had a history of chronic pain syndrome with long-term opioid use, post-op surgical wounds, and had ESRD requiring a renal diet. On 11/28/23 at 10:40 AM, registered nurses (RN #2 and RN#3, MDS coordinators) were interviewed. RN #2 verbalized that the admission Evaluation should be completed within 24 hours of admission and what is entered into the evaluation will populate a baseline care plan. Both RN's then reviewed R3's admission Evaluation and agreed the evaluation was not completed timely and the above mentioned care areas should have been care planned. On 11/28/23 at 11:00 AM, the above information was presented to the administrator, DON and nurse consultant. The administrator reviewed R3's baseline care plan and agreed the areas in question should have been care planned. No other information was presented prior to exit conference on 11/28/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of twelve residents in the survey sample (Resident #1). The findings include: Doses of Resident #1's medications that included IV (intravenous) ampicillin and IV gentamicin were unavailable for administration. Resident #1 (R1) was admitted to the facility with diagnoses that included cardiac valve infection, obesity, type 2 diabetes, cerebral infarction, chronic respiratory failure, liver cirrhosis, bacteremia, anemia, spleen infarction, hypertension and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented physician orders with start date of 10/12/23 for the following antibiotic medications. Ampicillin sodium intravenous (IV) solution - use 2 grams intravenously every 4 hours for treatment of infection. Gentamicin in saline solution 1-0.9 mg/ml (milligrams/milliliter) - use 40 mg intravenously every 12 hours for 30 days for treatment of infection. R1's medication administration record (MAR) documented the IV ampicillin was not administered as ordered on 10/12/23 at 12:00 a.m., 4:00 a.m. and 8:00 a.m. Nursing notes on 10/12/23 documented the ampicillin was not available to administer and listed the medication as awaiting delivery from pharmacy. R1's MAR documented the IV gentamicin was not administered on 10/13/23 at 9:00 p.m. as ordered because the medication was unavailable. A nursing note dated 10/13/23 documented, Nurse couldn't locate resident Gentamicin to give him is [his] 2100 [9:00 p.m.] dose. Nurse called pharmacy and it was on order. Nurse asked if it could be run stat. Pharmacy stated, 'It would be here in 3 hrs.' . (Sic) On 10/26/23 at 8:00 a.m., the director of nursing (DON) was interviewed about R1's unavailable antibiotic medications. The DON stated the pharmacy was supposed to deliver medications within four hours of order entry, but delivery was not always timely. The DON stated these medications (IV ampicillin and gentamicin) were not part of the emergency/backup medication supply so they had to be delivered from the pharmacy. The DON stated nurses call the pharmacy when these medications are not available, but deliveries were not always timely. This finding was reviewed with the administrator, DON, and regional nurse consultant during a meeting on 10/25/23 at 4:00 p.m. with no other information presented regarding the unavailable medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon staff interview and clinical record review, the facility staff failed to follow physician orders for one of twelve residents in the survey sample (Resident #1). The findings include: Resident #1's physician order for blood sugar checks before meals and at bedtime were not implemented as ordered for four days. Resident #1 (R1) was admitted to the facility with diagnoses that included cardiac valve infection, obesity, type 2 diabetes, cerebral infarction, chronic respiratory failure, liver cirrhosis, bacteremia, anemia, spleen infarction, hypertension and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented a physician's order with a start date of 10/12/23 for blood sugar checks to be obtained each day before meals and at bedtime. R1's medication administration record (MAR) for October 2023 had no order listed regarding blood sugar checks before meals and at bedtime. Nursing notes documented blood sugar checks on 10/13/23 at 8:00 a.m. and 11:11 a.m., on 10/14/23 at 4:25 p.m., on 10/15/23 at 9:06 a.m., and on 10/16/23 at 9:04 a.m. and 3:29 p.m. There were no other blood sugar checks documented other than those listed in nursing notes and those associated with a change in condition on 10/16/23. On 10/25/23 at 10:30 a.m., the director of nursing (DON) was interviewed about failure to implement R1's routine blood sugar checks as ordered by the physician. The DON stated the order was entered into the electronic health record by a nurse based upon a telephone order from the physician. The DON stated the nurse entering/confirming the order did not mark the order to display on the MAR. The DON stated R1's blood sugar checks were not obtained with the ordered frequency because the order was not displayed on the MAR. This finding was reviewed with the administrator, DON, and regional nurse consultant during a meeting on 10/25/23 at 4:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty-two residents in the survey sample (Resident #19). The findings include: Resident 19's annual MDS dated [DATE] failed to accurately assess the resident's dental problems. Resident #19 (R19) was admitted to the facility with diagnoses that included Alzheimer's disease, major depressive disorder, anxiety, hypothyroidism, schizoaffective mood disorder, dysphagia, congestive heart failure, and gastroesophageal reflux disease. The MDS dated [DATE] assessed R19 as cognitively intact. On 7/24/23 at 11:12 a.m., R19 was interviewed about quality of care/life in the facility. Resident #19 stated her teeth had been in bad shape for a long time. R19 displayed her teeth, revealing that most of her top teeth were missing and the lower front teeth were broken near the gum line with black/dark discoloration on the teeth surfaces. Several bottom teeth were also missing. Section L0200 of R19's MDS dated [DATE] documented that the resident had no dental problems. This category to indicate obvious or likely cavities or broken natural teeth was not marked. Item Z. was marked indicating R19 had no oral/dental problems. On 7/25/23 at 1:25 p.m., the registered nurse (RN #2) responsible for MDS assessments was interviewed about R19's dental assessment. RN #2 reviewed the 6/23/23 MDS and stated that R19's dental problems were not indicated on the assessment. RN #2 then stated that R19's poor dentition should have been marked/indicated under section L of the MDS. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages L-1 and L-2 documents regarding oral/dental assessment, .This item is intended to record any dental problems present in the 7-day look-back period .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m., with no further information presented about the inaccurate MDS prior to the end of the survey. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty-two residents in the survey sample (Resident #19) The findings include: Resident #19 (R19), assessed with severely impaired vision, had no plan of care regarding blindness/vision impairment. Resident #19 was admitted to the facility with diagnoses that included Alzheimer's disease, major depressive disorder, anxiety, hypothyroidism, schizoaffective mood disorder, dysphagia, congestive heart failure, and gastroesophageal reflux disease. The MDS dated [DATE] assessed R19 as cognitively intact and with severely impaired vision. On 7/24/23 at 11:17 a.m., R19 was interviewed about quality of care/life in the facility. R19 stated that she had poor vision and was only able to see shadows. Resident #19 stated that staff assisted her daily with placing items in familiar places and informing her about the location of needed items. Resident #19's MDS dated [DATE] included vision as a triggered concern in the care area assessment summary and was marked that care planning was done regarding visual function. Resident #19's comprehensive plan of care (revised 7/10/23) included no problems, goals and/or interventions regarding the R19's vision impairment. On 7/25/23 at 1:30 p.m., the registered nurse (RN #2) responsible for MDS/care plans was interviewed. RN #2 stated that if a care area triggered on the MDS, the concern should be on the comprehensive plan of care. RN #2 reviewed R19's care plan and stated that there was no plan regarding visual impairment. RN #2 stated, There should be a care plan regarding poor vision. This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no further information presented regarding the care plan prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to apply a wander prevention device as required in the plan of care for one of twenty-two residents in the survey sample (Resident #25). The findings include: Resident #25 (R25) was admitted to the facility with diagnoses that included adult failure to thrive, atherosclerotic heart disease, hypertension, chronic kidney disease, dementia, psychotic/mood disturbance, anxiety and thrombocytopenia. The minimum data set (MDS) dated [DATE] assessed R25 with severely impaired cognitive skills. R25's comprehensive plan of care (revised 6/20/23) documented that R25 was at risk of wandering/elopement due to disorientation, poor safety awareness, aimless wandering, and a history of attempts to leave the facility. Interventions to maintain safety included, .wander guard on at all times . R25's treatment administration record for July 2023 documented placement of the wander prevention device each shift, and function of the wander prevention device checked daily on the night shift. Resident #25's clinical record documented a physician's order dated 6/14/23 to, Check placement of wander bracelet every shift .Wander bracelet - Check function daily. On 7/25/23 at 8:36 a.m., R25 was observed seated on the bedside. There was no wander prevention device observed on either wrist or ankle. On 7/25/23 at 9:28 a.m., accompanied by certified nurses' aide (CNA) #1, Resident #25 was observed for use of the wandering prevention device. CNA #1, with R25's permission, displayed the resident's wrists and ankles with no wander prevention bracelet observed in use. CNA #1 stated at this time that R25 previously had a Wanderguard device, but she did not know what happened to it. CNA #1 searched R25's walker, wheelchair, beside table, and storage drawers, and then stated that she had not found the device. CNA #1 stated that R25 got up and walked independently with the walker, as well as self-propelling in the wheelchair. On 7/25/23 at 9:34 a.m., the registered nurse (RN #3) caring for R25 was interviewed about the wander prevention device. RN #3 checked R25's clinical record and stated that R25 had a physician's order for a wandering device and that she did not know why the device was not in use. On 7/25/23 at 3:16 p.m., the licensed practical nurse (LPN #3) unit manager was interviewed. LPN #3 stated R25 had a history of exit seeking, increased confusion when he had a urinary tract infection, but had never eloped from the facility. LPN #3 stated that R25 was supposed to have a wander prevention device and at times had attempted to remove the device. LPN #3 stated that prior to today, the wander prevention device had been observed on R25's right wrist. This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no other information presented about the safety device prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure medication was available for administration for two of four residents during the medication pass and pour observation (Resident #8 and Resident #89). 1. 2. The Findings Include: 1. Resident #8's (R8) Telmisartan 40 milligrams (given for hypertension) was unavailable for administration as ordered by the physician. During a medication pass and pour observation conducted on 7/25/22 at 8:00 AM, Resident #8 (R8) was scheduled to receive Telmisartan 40 MG at 8AM. Licensed practical nurse (LPN #2) looked into the medication cart and verbalized that the medication was not available to give. LPN #8 then called the pharmacy and relayed that it was stated that the medication would be arriving later in the day. On 7/25/23 at 10:04 AM, LPN #2 was asked when do nurses reorder medications. LPN #2 said that she usually reorders medication when there are 5 pills left to distribute. LPN #2 was then able to look up when the medication was ordered and verbalized that the Telmisartan had been ordered on 7/24/23 (day prior to the medication observation). LPN #2 then reviewed the medication administration record and verbalized that R8 had received the medication on 7/24/23. The physician's order for R8's Telmisartan was reviewed and documented: Telmisartan 40 MG Tablet 10 MG one time a day dispense 9:00 AM. On 5/25/23 at 4:10 PM, the above finding was presented to the director of nursing, administrator, and nurse consultant. A policy titled Ordering and Receiving Non-controlled Medications read in part Reorder medications based on estimated refill date on the pharmacy label, or at least three days in advance, to ensure an adequate supply is on hand. No other information was presented prior to exit conference on 7/26/23. 2. Resident #89's (R 89) Paroxetine 10 milligrams was unavailable for administration as ordered by the physician. A medication pass observation was conducted on 7/25/23 at 7:54 a.m. with registered nurse (RN #3) administering medications to Resident #89 (R89). Medications administered to R89 included Paroxetine 20 mg (milligrams). RN #3 stated at the time of administration that the 10 mg tablet of Paroxetine was not in the medication cart. Resident #89's clinical record documented a physician's order dated 5/11/23 for Paroxetine 30 mg each day for treatment of depression. On 7/25/23 at 9:11 a.m., RN #3 was interviewed about the unavailable Paroxetine 10 mg for Resident #89. RN #3 stated the Paroxetine was supplied from the pharmacy with a 20 mg and a 10 mg tablet to equal the ordered 30 mg dose. RN #3 stated the Paroxetine 10 mg was not in the medication cart and was not in the backup supply. On 7/25/23 at 9:25 a.m., RN #3 stated that the Paroxetine 10 mg had been reordered on 7/23/23 but had not yet arrived from the pharmacy. RN #3 stated that it typically took two to three days for routine delivery of ordered medications and that Paroxetine was not a medication kept in the backup supply. On 7/25/23 at 1:08 p.m., the director of nursing (DON) was interviewed about the unavailable Paroxetine. The DON stated that nurses were expected to reorder medications three to five days prior to running out in order to maintain a supply. The DON stated that reorders were entered/processed from the computer system. The facility's policy titled Ordering and Receiving Non-Controlled Medications (revised 08/2020) documented, .Medication and related products are received from the pharmacy on a timely basis .Reordering medications is done in accordance with the order and delivery schedule established by the pharmacy provider .Reorder medications based on the estimated refill date ([NAME]) on the pharmacy Rx label, or at least three days in advance, to ensure an adequate supply is on hand . This finding was reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no further information presented about the unavailable medication prior to the end of the survey.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed five errors out of forty-one opportunities, resulting in a 12.2% error rate The Findings Include: 1. Resident #2 (R2) was given the wrong dose of Calcium. During a medication pass and pour observation conducted on 7/25/23 at 8:00 AM, license practical nurse (LPN #2) began pulling medications out of the medication cart for R2 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Calcium 600 MG (milligrams) with Vitamin D 5 mcg (micrograms). LPN #1 dispensed the medication into the medication cup and administered to R2. R2's physician's orders were then reviewed to verify accuracy of medications given. There was a physician's order to give Calcium 500 MG/VIT D 400 IU (international units), a combination medication for osteoporosis, which differed from the calcium that had been administered. On 7/25/23 at 11:07 AM, the ADON (assistant director of nursing) discussed the observation findings with this surveyor and verbalized that the wrong dosage of calcium and vitamin D had been given, that the nurse practitioner was made aware, and that the order had been changed to the medication that the pharmacy had delivered. On 7/25/23 at 4:10 PM the above information was presented to the director of nursing (DON) and administrator. No other information was presented prior to exit on 7/12/23. 2. Resident #8 (R #8) was not given Telmisartan 40 MG as ordered (given for hypertension). During a medication pass and pour conducted on 7/25/22 at 8:00 AM, Resident #8 (R #8) was scheduled to receive Telmisartan 40 MG. Licensed practical nurse (LPN #2) looked into the medication cart and verbalized that the medication was not available to give. LPN #2 then called the pharmacy and relayed the information that the medication would be arriving until later in the day. On 7/25/23 at 10:04 AM, LPN #2 was asked what is the time period for giving a scheduled medication. LPN #2 verbalized a medication can be given an hour before or after the scheduled time. The physician's order for R #8's Telmisartan was reviewed and documented: Telmisartan 40 MG Tablet 10 MG one time a day . dispense 9:00 AM. On 7/25/23 at 10:45 AM, LPN #2 verbalized R #8's medication had arrived. The medication was reviewed for correct medication and dose and was then administered to R #8. On 5/25/23 at 4:10 PM, the above finding was presented to the director of nursing, administrator, and nurse consultant. The DON agreed that medications are to be given within the standard administration range of an hour before or after the scheduled time. No other information was presented prior to exit conference on 7/26/23. 3. Resident #89 (R 89) was given the wrong dose of Paroxetine, Senna instead of Senna with stool softener, and Breo Ellipta was administered but no followed by the mouth rinse. A medication pass observation was conducted on 7/25/23 at 7:54 a.m. with registered nurse (RN #3) administering medications to Resident #89 (R89). Medications administered to R89 included Paroxetine 20 mg (milligrams), Geri-kot senna 8.6 mg, and Breo Ellipta 200 mcg/25 mcg. R89 did not rinse her mouth after the inhalation of the Breo Ellipta and there was no prompting or request by RN #3 instructing R89 to do so. R89's clinical record documented a physician's order dated 5/11/23 for Paroxetine 30 mg each day for treatment of depression, a physician's order dated 6/8/23 for Senna-Docusate sodium 8.6 mg/50 mg two times per day for constipation, and a physician's order dated 5/15/23 for Breo Ellipta inhalation aerosol powder 200-25 mcg/activation, one puff inhaled orally each day for management of emphysema with instructions to, Rinse mouth after administration to prevent candidiasis [mouth infection]. No physician's order was found for the plain Senna 8.6 mg. On 7/25/23 at 9:11 a.m., RN #3 was interviewed about the medications observed as being administered not as ordered by the physician. RN #3 stated that the Paroxetine was supplied from pharmacy in a 20 mg and 10 tablet to equal the needed 30 mg dose. RN #3 stated that the 10 mg tablet was not available in the medication cart and it was not in the backup supply. RN #3 stated that the senna products were ordered in-house and she was not sure if the senna-docusate sodium product was in the cart. RN #3 stated that she did not think about prompting or instructing the resident to rinse her mouth after the inhaled dose Breo Ellipta powder. The facility's pharmacy information for the medication Breo Ellipta (issue date 7/19/23) documented under instructions for administration, Rinse out mouth after each use. Do not swallow the rinse water. Spit it out . These findings were reviewed with the administrator and director of nursing during a meeting on 7/25/23 at 4:10 p.m. with no further information presented about the medication errors prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices regarding hand hygiene during a dressing change for one of twenty-two residents in the survey sample (Resident #25) and on one of two units during the medication pass (unit 2). The findings include: 1. Infection control practices regarding hand hygiene were not followed during a dressing change to Resident #25's foot callous. Resident #25 (R25) was admitted to the facility with diagnoses that included adult failure to thrive, atherosclerotic heart disease, hypertension, chronic kidney disease, dementia, psychotic/mood disturbance, anxiety and thrombocytopenia. The minimum data set (MDS) dated [DATE] assessed R25 with severely impaired cognitive skills. Resident #25's clinical record documented the resident had a callous on the plantar surface of the right foot with a physician's order dated 7/18/23 for Bacitracin and a dry dressing applied to the wound each day shift. On 7/24/23 at 3:25 p.m., registered nurse (RN #3) was observed performing a dressing change to R25's right foot callous. RN #3 washed hands and directly touched the faucet handles when turning off the water and prior to drying her hands with a paper towel. RN #3 then put on clean gloves, removed the soiled dressing from the right foot and discarded it. Without performing hand hygiene or changing gloves, RN #3 applied Bacitracin to the new dressing and applied the clean dressing to the right foot callous. The calloused area was approximately dime sized, flat, intact with pink/red skin surrounding the callous. On 7/24/23 at 3:35 p.m., RN #3 was interviewed about the handwashing and not changing gloves after removing the soiled dressing. RN #3 stated that she forgot and was aware to perform hand hygiene and change gloves after removing an old dressing. 2. RN #3 performed improper hand hygiene during a medication pass observation on unit 2. A medication pass observation was conducted on 7/25/23 at 7:54 a.m. with registered nurse (RN #3) administering medications to Resident #89 (R89) and Resident #25 (R25). Prior to preparing medications for R89, RN #3 washed her hands and directly touched the faucet handle when turning off water and prior to drying hands with a paper towel. RN #3 then administered medications to R89 and washed hands again, touching the faucet handle prior to drying her hands. RN #3 then prepared and administered medications to R25. RN #3 washed her hands after the medication administration in the same manner, directly touching the faucet handle with a bare hand prior to drying her hands with a paper towel. On 7/25/23 at 8:38 a.m., RN #3 was interviewed about washing hands and then touching the faucet handles. RN #3 stated, Sometimes I forget when I'm rushing. RN #3 stated she was nervous and knew she was noy supposed to touch the faucet handles after washing hands. On 7/26/23 at 8:53 a.m., the licensed practical nurse (LPN #4) responsible for infection prevention programs was interviewed about hand hygiene. LPN #4 stated nurses were not expected to touch faucet handles after washing hands but instead use their elbow or paper towel to turn off the water. LPN #4 stated a glove change and proper hand hygiene were expected after removal of a soiled dressing. LPN #4 stated RN #3 had been educated before about improper hand hygiene. The facility's policy titled Clean Dressing (undated) documented steps for a clean dressing change that included, .Wash and dry your hands thoroughly .Put on clean gloves. Loosen tape and remove soiled dressing .Pull glove over dressing and discard into plastic or biohazard bag .Wash and dry your hands thoroughly .Open, dry, clean dressing .Wash and dry your hands thoroughly .Put on clean gloves .Apply the ordered dressing and secure with tape or bordered dressing per order . The facility's policy titled Hand Hygiene (undated) documented, .This facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene . Procedures for proper handwashing included, .Wet hands and wrist .Apply enough soap to cover all of hand surfaces .Vigorously rub lathered surfaces .for at least 20 seconds .Rinse wrists and hands thoroughly under a stream of running water .Dry hands completely with a clean paper towel .Use dry paper towel to turn faucet off . These findings were reviewed with the administrator and director of nursing during meetings on 7/25/23 at 4:10 a.m. and on 7/26/23 at 12:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent potential foodborne illness for 93 out of 94 residents (1 resident was receiving tube feedings). Specifically, the main kitchen freezer was found to have improperly labeled foods in the freezer and three out of four-unit pantry refrigerators were found to be improperly labeled and had expired food items. This failure had the potential to expose residents to expired and/or spoiled food, unknown allergens, and food items that were not in compliance with current dietary orders. Findings include: Review of the undated facility policy titled, Receiving and Storage of Food revealed, Foods shall be received and stored in a manger that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times .All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date.) .Food items and snacks kept on the nursing units must be maintained as indicated .a. All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses' station and labeled with a use by date, b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date, c. Refrigerators must have working thermometers and be monitored for temperature, d. Beverages must be dated when opened and discarded after 24 hours, e. Other opened containers must be dated and sealed or covered during storage, f. partially eaten food may not be kept in the refrigerator. Review of the undated facility policy titled Refrigerators and Freezers revealed, The facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation and will observe food expiration guidelines .All food will be appropriately dated to ensure proper rotation by expiration dates .Use by dates may be completed with expiration dates on all prepared food in refrigerator .Expiration dates on unopened food will be observed and use by dates indicated once food is opened .Supervisors/designee will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past perish dates. A tour of the kitchen on 07/24/23 at 10:22 AM was conducted with the Food Service Manager (FSM)2. In the main freezer an opened, undated, and unlabeled cake was observed. FSM2 stated that she did not know what the cake was and immediately discarded it. Additionally, an opened, undated, and unlabeled blue plastic bag of unidentified contents was observed. FSM2 stated that they were lima beans and immediately discarded the food item. A tour of the Unit Pantry refrigerators, which was where the residents could store their food from outside and where Food Services provided beverages and small snacks for the residents, was conducted on 07/26/23 at 8:27 AM, with the corporate Food Service Director (FSD)1 and FSM2. In the refrigerator on the first-floor unit pantry a white plastic bag was observed on the door of the refrigerator. The bag had a resident's name on it (Resident (R) 54) and was dated 07/12/23. FSM2 opened the bag which appeared to contain sliced meat and cheese. There was also a bag containing bottled smoothies with R92's name on them and a date of 07/22/23. (R92's diet order was nothing by mouth (NPO) at the time of the tour.) The Licensed Practical Nurse (LPN) 1 on the unit stated that the process [when resident's keep food in the refrigerator] is that if family brings in a food item for a resident, it should have a name, date, and room number. On the 2nd floor, observation of the North unit pantry revealed that there was no thermometer in the refrigerator. A Certified Nursing Assistant (CNA) 2 who was near the refrigerator area was immediately interviewed. CNA2 stated, Food that comes in from the residents should be labeled, dated, and have a room number on it. CNA2 stated that it should be three days from when the food item comes in until it is discarded. When questioned, CNA2 did not know where the thermometer was. An observation of the freezer revealed that there was an unlabeled, undated bag of frozen food items in a Walmart bag, with the designation room [ROOM NUMBER] on it. On the 2nd floor South unit pantry, CNA1 stated that when a food item comes in from outside it should be dated and labeled with the resident's room number. CNA1 stated that the 11pm-7am CNA is responsible for doing the temperatures. Observation of the refrigerator revealed the following: 1. an opened, unlabeled, undated 20-ounce container of mayonnaise was observed. CNA1 stated that she didn't know who's that [the mayonnaise] was and that they [the staff] probably just used it if someone [a resident] asked for mayonnaise; 2. an unlabeled, undated 20-ounce container of mustard was observed; 3. an unlabeled, undated 16-ounce container of what looked to be a reddish jar of non-store-bought preserves was observed; 4. an opened, unlabeled, undated 15-ounce bottle of lemon juice was observed; and 6. An unlabeled, undated expired 6-ounce container of yogurt was noted in the door of the refrigerator with a manufacturer's expiration date of 07/18/23. Observation of the freezer compartment revealed an unlabeled, undated, one-quart container of ice cream. During the unit pantry tour on 07/26/23 at 8:43 AM, FSM2 was interviewed. FSM2 revealed that the kitchen was responsible for restocking the soda, pudding, apple sauce, and milk, while the nursing staff was responsible for taking the temperatures in the refrigerator and managing the items that came in from resident family members. FSM2 indicated the sign on the refrigerator that stated Please label resident food items with name and date, place in fridge. Items will be discarded if not labeled and dated. All food items will be discarded after 72 hours.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to implement policies and procedures to ensure one of five residents, Resident #3, was offered the COVID-19 vaccine. Findings were: Resident #3 was admitted to the facility with diagnoses that included, but not limited to, epilepsy, unsteadiness on feet, muscle weakness, history of falling, dementia, and cerebral infarction. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/17/2023, contained a staff assessment for Resident #3's mental status. Resident #3 was assessed as memory OK for short and long term memory and as modified independence in daily decision making skills. As part of the focused infection control survey process, Resident #3 was added to the survey sample to ascertain his vaccination status. The clinical record was reviewed on 02/13/2023 at approximately 1:00 p.m., but did not contain any documentation regarding a COVID vaccine. LPN (licensed practical nurse) #1 was interviewed at approximately 1:15 p.m., regarding the process for assessing residents for vaccination status. LPN #1 stated, I get a Virginia vaccine record on all the residents before they are admitted . LPN #1 pulled Resident #3's vaccine record up in the EHR and stated, It doesn't look like he got it .I also see that he refused it in the hospital before he came here. LPN #1 was asked if the vaccine had been offered at admission and where would the documentation be located. LPN #1 pulled up the immunization screen in the EHR and stated, It should be here. The screen was blank. The facility COVID-19 vaccination policy was requested. Per the policy COVID-19 Vaccination for Residents: * Prior to admission, the facility will validate COVID-19 vaccination status. * Resident/resident representatives will be educated on: a). risks/benefits of COVID-19 vaccination. The education will be specific to vaccine being offered/administered . * Residents will be encouraged to accept COVID-19 vaccination . * If the resident/resident representative refuses administration of the COVID-19 vaccine, education will be provided to the resident and the resident's refusal will be documented in the resident's medical record No documentation of the vaccine being offered, education given, or refusal of the vaccine was observed. The above information was discussed during a meeting with the DON (director of nursing) and LPN #1 on 02/13/2023 at approximately 2:15 p.m. When asked what should have happened when Resident #3 was admitted , LPN #1 stated, We should offer all vaccines on admission even if they have refused before and document the information in the clinical record. No further information was obtained prior to the exit conference on 02/13/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #3 was not offered a pneumococcal vaccine at the time of admission to the facility. Resident #3 was admitted to the facility with the following diagnoses, including but not limited to: epilepsy, unsteadiness on feet, muscle weakness, history of falling, dementia, and cerebral infarction. Resident #3's admission MDS (minimum data set) with an ARD (assessment reference date) of 01/17/2023, contained a staff assessment for mental status. Resident #3 was assessed as memory OK for short and long term memory and as modified independence in daily decision making skills. As part of the focused infection control survey process, Resident #3 was added to the survey sample to ascertain his vaccination status. The clinical record was reviewed on 02/13/2023, at approximately 1:00 p.m. A screen labeled Immunizations on the electronic health record (EHR) was reviewed. There were no entries observed. The admission MDS section O Special Treatments, Procedures, and Programs was reviewed. Entry O0300 Pneumococcal Vaccine contained the following: Is the resident's Pneumococcal vaccination up to date? The answer was coded as No. If Pneumococcal vaccination not received, state reason: Not offered. LPN (licensed practical nurse) #1 was interviewed at approximately 1:15 p.m., regarding the process for assessing residents for vaccination status. LPN #1 stated, I get a Virginia vaccine record on all the residents before they are admitted . LPN #1 pulled Resident #3's vaccine record up in the EHR and stated, It doesn't look like he got it . LPN #1was asked if vaccines were offered at admission and where would the documentation be located. LPN #1 pulled up the immunization screen in the (EHR)and stated, It should be here. The screen was blank. The facility policy Pneumococcal Vaccine was reviewed and contained the following: Residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Residents of the long term care facility will be offered the pneumococcal vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control .Before offering pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization .If a resident or resident's representative refuses to have the pneumonia vaccine administered, the attending physician will be notified, and documentation of the refusal and physician notification will be documented in the nursing notes. No documentation of the pneumococcal vaccine being offered, education given, or refusal of the vaccine was observed in the clinical record. The above information was discussed during a meeting with the DON (director of nursing) and LPN #1 on 02/13/2023 at approximately 2:15 p.m. When asked what should have happened when Resident #3 was admitted , LPN #1 responded, We should offer all vaccines on admission, even if they have refused before, and document the information in the clinical record. No further information was obtained prior to the exit conference on 02/13/2023. Based on resident interview, family interview, staff interview, facility policy review and clinical record review, the facility staff failed to offer and/or document pneumococcal immunization status for three of five residents in the survey sample (Residents #3, #4 and #5). The findings include: 1. Resident #4's clinical record documented no evidence that the pneumococcal vaccine was offered, received or refused, as well as no evidence that the resident and/or resident's representative was educated about the benefits and potential side effects of the immunization. Resident #4 was admitted to the facility with diagnoses that included dysphagia, anemia, diabetes, hypertension, schizophrenia, history of COVID-19 and mood disorder. The minimum data set (MDS) dated [DATE] assessed Resident #4 with moderately impaired cognitive skills for daily decision making. Review of Resident #4's clinical record revealed no documentation regarding the resident's pneumococcal immunization status. The pneumococcal vaccination status was not listed under the immunization tab along with the influenza and COVID-19 vaccines. There was no documentation the resident or family had been educated on the benefits and possible side effects of the vaccine. On 2/13/23 at 1:15 p.m., the licensed practical nurse (LPN #1) responsible for tracking vaccinations was interviewed about Resident #4's pneumococcal immunization status. LPN #1 stated that Resident #4's clinical record documented the influenza and COVID-19 vaccinations but not the pneumococcal. LPN #1 stated that the pneumococcal vaccines had been offered to residents, but she had not updated clinical records with the status, education or refusals. On 2/13/23 at 1:25 p.m., Resident #4 was interviewed about her immunization status. Resident #4 stated the facility had previously offered and provided education on all immunizations, but she did not remember when they were discussed. Resident #4 stated, I don't want any of them [vaccines]. On 2/13/23 at 2:10 p.m., the director of nursing (DON) and LPN #1 were interviewed about Resident #4's pneumococcal immunization status. The DON stated she did not know Resident #4's current pneumococcal immunization status. The DON stated that the former assistant director of nursing documented immunizations in a book that was not part of the clinical record, and that she did not know where the book was located. The DON stated immunization status was supposed to be determined upon admission, documented in the clinical record, and updated as needed. LPN #1 stated she had been told to only record influenza and COVID-19 vaccines in the clinical record. This finding was reviewed with the DON and the regional MDS coordinator during a meeting on 2/13/23 at 2:15 p.m. The administrator was out of the facility during the survey. 2. Resident #5's clinical record documented no evidence that the pneumococcal vaccine was offered, received or refused, as well as no evidence that the resident and/or resident's representative was educated about the benefits and potential side effects of the immunization. Resident #5 was admitted to the facility with diagnoses that included gastroenteritis, deep vein thrombosis, vertebral compression fractures, anemia, protein-calorie malnutrition and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed the resident with moderately impaired cognitive skills for daily decision making. Review of Resident #5's clinical record revealed no documentation regarding the resident's pneumococcal immunization status. The pneumococcal vaccination status was not listed under the immunization tab along with the influenza and COVID-19 vaccines. There was no documentation that the resident or family had been educated on the benefits and possible side effects of the vaccine. On 2/13/23 at 1:15 p.m., the licensed practical nurse (LPN #1) responsible for tracking vaccinations was interviewed about Resident #5's pneumococcal immunization status. LPN #1 stated Resident #5's clinical record documented the influenza and COVID-19 vaccinations but not the pneumococcal. LPN #1 stated that the pneumococcal vaccines had been offered to residents, but she had not updated clinical records with the status, education or refusals. On 2/13/23 at 1:20 p.m., Resident #5's family members were interviewed about his pneumococcal immunization status. Resident #5's family members stated the facility had offered and provided an education sheet about immunizations around the time of admission. Resident #5's family members stated the resident refused all the vaccines, as he had experienced a reaction to an influenza vaccine prior to his admission. On 2/13/23 at 2:10 p.m., the director of nursing (DON) and LPN #1 were interviewed about Resident #5's pneumococcal immunization status. The DON stated that she did not know Resident #5's current pneumococcal immunization status. The DON stated that immunization status was supposed to be determined upon admission, documented in the clinical record, and updated as needed. LPN #1 stated that she had been told to only record influenza and COVID-19 vaccines in the clinical record. This finding was reviewed with the DON and the regional MDS coordinator during a meeting on 2/13/23 at 2:15 p.m. The administrator was out of the facility during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview and clinical record review, the facility staff failed to notify the physician and resident representative of an elopement for one of twenty-two residents in the survey sample, Resident #9. Resident #9's family and physician were not notified when the resident was found out of the facility unsupervised. The findings include: Resident #9 was admitted to the facility with diagnoses that included vascular dementia with behavioral disturbance, vitamin D deficiency, major depressive disorder, hypothyroidism, atherosclerotic heart disease, benign prostatic hyperplasia, hypertension and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #9 with severely impaired cognitive skills. On 5/10/22 at 2:18 p.m., Resident #9's family member was interviewed about quality of care in the facility. The family member stated the resident was found several days ago by hospital staff wandering in the adjacent hospital without supervision. The family member stated she heard this from a person that did not work for the facility and thought the resident's Wanderguard device was not working. The family member stated nobody from the facility informed the family of the incident and family was upset that they were not made aware of the incident and heard about the incident in the community. Resident #9's clinical record documented a physician's order dated 12/10/21 for a Wanderguard elopement prevention device with instructions to check the device each shift to ensure function and replace if needed. Resident #9's plan of care (revised 4/22/22) listed the resident had impaired cognitive function, was an elopement risk due to wandering, and used an elopement prevention device. Resident #9's clinical record for May 2022 documented no incidents of elopement and no notifications to the family or physician about an elopement. On 5/11/22 at 11:13 a.m., the licensed practical nurse (LPN) #2 caring for Resident #9 was interviewed about any recent elopements. LPN #2 stated it was communicated during shift report that Resident #9 was found by hospital staff and brought back to the facility. LPN #2 stated this happened in the last couple of weeks but she did not know the date of the incident. On 5/11/22 at 11:33 a.m., the director of nursing (DON) was interviewed about Resident #9's elopement. The DON stated she heard about the incident in the stand-up meeting on Monday (5/9/22). The DON stated the incident was not reported to the administrator, physician or family. The DON stated the incident should have been reported when it happened to facility administration and notification made to the provider and family. On 5/11/22 at 3:00 p.m., the administrator was interviewed about the elopement incident with Resident #9. The administrator stated the resident's daughter called her yesterday (5/10/22) and reported she heard the resident was found in the adjacent hospital. The administrator stated she had not been notified by facility staff about the incident. The administrator stated the incident happened on 5/8/22 with LPN #3 working. The administrator stated she had not yet talked with LPN #3 about the details of the incident. On 5/12/22 at 9:43 a.m., LPN #3 that cared for Resident #9 on 5/8/22 was interviewed. LPN #3 stated she was administering medications during the evening shift on 5/8/22 when a therapist and another hospital employee brought Resident #9 back to the unit. LPN #3 stated the hospital staff found the resident wandering on the medical-surgical unit of the hospital which is on the connecting floor to the facility. LPN #3 stated the incident occurred between 8:00 p.m. and 10:00 p.m. LPN #3 stated she did not call the family because it was late and did not notify the physician and/or provider because the resident was not hurt. The facility's policy titled Elopement/Missing Person (undated) defined elopement as, .a disoriented or confused resident or a resident who has been determined to be at risk for elopement, leaves the nursing facility premises without notification to the staff or escort . This policy documented, .It is the responsibility of all staff members to report immediately to the administrator or DON or Nursing Supervisor, and resident attempting to leave the premise or is suspected of not being on the premises without properly checking out in accordance with established policy and procedures . (sic) This policy documented the nursing supervisors or a designee would notify the physician and the resident's responsible party of elopement events and actions taken. This finding was reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to follow the abuse policy to report and investigate an injury of unknown orgin in a timely manner. The findings include: Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section G - Functional Status, the MDS assessed Resident #51 as requiring extensive assistance with one person physical assistance for dressing, personal hygiene, bed mobility, and toileting; total dependent for bathing; and supervision for eating. On 05/10/2022 during the initial tour Resident #51 was observed lying in bed asleep. A bruise was observed on Resident #51's right eye. Resident #51's clinical record was reviewed and documented the following progress note: 5/9/2022 13:18 (1:18 p.m.) NURSES NOTE Note Text: nurse on previous shift reported resident having a bruise on the side of her right eye. this nurse went in to check on resident at shift change, there is a bruise around right eye and resident is unsure how it happened. On 05/11/2022 at 8:45 a.m., the licensed practical nurse (LPN) #2 who routinely provided care for Resident #51 and identified as the nurse who wrote the note on 05/09/2022, was interviewed about the bruise. LPN #2 stated I was off over the weekend and when I returned to work on Monday. The nurse on the previous shift reported to me about the bruise. I reviewed the chart and saw there were no notes written so I wrote the note and notified the DON (director of nursing) who stated she would take care of the investigation. I can't say what happened because I wasn't here but looking at the location of the bruise I think she may have hit it (eye) on the bedside table because of the way she lays and attempts to get up. On 05/11/2022 at 09:17 a.m., the DON was interviewed about the bruise and investigation. The DON stated, (LPN #2) did report the bruise to me on Monday and I guess it happened over the weekend. The DON was asked if the injury had been reported to the administrator, physician and the State Agency. The DON stated, No, I wasn't notified over the weekend and neither was the administrator so no one has been notified yet. The DON was asked if an investigation had been started. The DON stated, No, I just haven't gotten around to it. The DON was asked if she was aware of the time frames to report injuries of unknown origin and to start an investigation. The DON stated, Yes it's all within the abuse policy. On 05/11/2022 at 11:30 a.m., the DON stated a full skin assessment had been completed a few minutes earlier. The DON stated the administrator was in the process of starting the investigation and notifying the State Agency, responsible party, physician, adult protective services. On 05/11/2022 at 3:04 p.m., the administrator was interviewed. The administrator stated she was waiting for a return call from the identified weekend nurse (LPN #3) who reported the bruise to LPN #2. The administrator was asked if she was notified of the bruise. The administrator stated, No, not until the DON told me about it. The administrator was asked if staff were trained on the abuse policy and reporting of injuries of unknown origin. The administrator stated, Yes (LPN #3) is one of our permanent full-time nurses and they all have been trained on the abuse policy including reporting any incidents to me. The above findings were discussed with the administrator and DON during a meeting on 05/11/2022 at 5:30 p.m. On 05/12/2022 at 9:40 a.m., LPN #3 was interviewed. LPN #3 stated, I worked overnight Sunday into Monday morning. The day shift nurse (LPN #2) told me that a CNA told her they saw a bruise on (Resident #51) eye that morning. I told (LPN #2) that I didn't see a bruise overnight. I changed (Resident #51) Sunday night and I didn't want to fully wake her up so I only turned on the light over the head of the bed. I don't recall seeing a bruise, if I had I would have written it up and notified the DON and/or the administrator. LPN #3 was asked if she knew which CNA told LPN #2 about the bruise. LPN #3 stated, No. On 05/12/2022 at 10:30 a.m., LPN #2 was asked which CNA told her about the bruise on Resident #51's eye. LPN #2 stated, I was told about the bruise by the nurse (LPN #3) not the aide. A review of the facility's Abuse Policy documented the following: .5. Investigation. Designated staff will immediately review and investigate all allegations or observations of abuse .6. Protection. a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident .6. Reporting a. The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including the State Survey Agency and adult protective services where state law provides all jurisdiction in long-term care facilities) in accordance with State law through established procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to report an injury of unknown origin to the state agency in a timely manner. The findings include: Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section G - Functional Status, the MDS assessed Resident #51 as requiring extensive assistance with one person physical assistance for dressing, personal hygiene, bed mobility, and toileting; total dependent for bathing; and supervision for eating. On 05/10/2022 during the initial tour Resident #51 was observed lying in bed asleep. A bruise was observed on Resident #51's right eye. Resident #51's clinical record was reviewed and documented the following progress note: 5/9/2022 13:18 (1:18 p.m.) NURSES NOTE Note Text: nurse on previous shift reported resident having a bruise on the side of her right eye. this nurse went in to check on resident at shift change, there is a bruise around right eye and resident is unsure how it happened. On 05/11/2022 at 8:45 a.m., the licensed practical nurse (LPN) #2 who routinely provided care for Resident #51 and identified as the nurse who wrote the note on 05/09/2022, was interviewed about the bruise. LPN #2 stated I was off over the weekend and when I returned to work on Monday. The nurse on the previous shift reported to me about the bruise. I reviewed the chart and saw there were no notes written so I wrote the note and notified the DON (director of nursing) who stated she would take care of the investigation. I can't say what happened because I wasn't here but looking at the location of the bruise I think she may have hit it (eye) on the bedside table because of the way she lays and attempts to get up. On 05/11/2022 at 09:17 a.m., the DON was interviewed about the bruise and investigation. The DON stated, (LPN #2) did report the bruise to me on Monday and I guess it happened over the weekend. The DON was asked if the injury had been reported to the administrator, physician and the State Agency. The DON stated, No, I wasn't notified over the weekend and neither was the administrator so no one has been notified yet. The DON was asked if an investigation had been started. The DON stated, No, I just haven't gotten around to it. The DON was asked if she was aware of the time frames to report injuries of unknown origin and to start an investigation. The DON stated, Yes it's all within the abuse policy. On 05/11/2022 at 11:30 a.m., the DON stated a full skin assessment had been completed a few minutes earlier. The DON stated the administrator was in the process of starting the investigation and notifying the State Agency, responsible party, physician, adult protective services. On 05/11/2022 at 3:04 p.m., the administrator was interviewed. The administrator stated she was waiting for a return call from the identified weekend nurse (LPN #3) who reported the bruise to LPN #2. The administrator was asked if she was notified of the bruise. The administrator stated, No, not until the DON told me about it. The administrator was asked if staff were trained on the abuse policy and reporting of injuries of unknown origin. The administrator stated, Yes (LPN #3) is one of our permanent full-time nurses and they all have been trained on the abuse policy including reporting any incidents to me. A copy of the facility reported incident (FRI) dated 05/11/2022 documented the facility reported the injury of unknown origin as a bruise to right corner eye. The FRI documented the responsible party, physician, adult protective services and department of health professionals were notified on 05/11/2022. The above findings were discussed with the administrator and DON during a meeting on 05/11/2022 at 5:30 p.m. A review of the facility's Abuse Policy documented the following: .5. Investigation. Designated staff will immediately review and investigate all allegations or observations of abuse . .6. Protection. a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident . .6. Reporting a. The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including the State Survey Agency and adult protective services where state law provides all jurisdiction in long-term care facilities) in accordance with State law through established procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to obtain order for the immediate care of Stage IV sacral pressure ulcer for one of 22 residents, Resident #73. Findings were: Resident #73 was admitted to the facility with the following diagnoses including but not limited to: osteoarthritis, hypertension, morbid obesity, acute respiratory failure, diabetes mellitus, and Stage IV Sacral pressure ulcer. Due to her recent admission there was no MDS (minimum data set) assessment. According to her admission assessment dated [DATE], she was oriented to person, place, time, and situation. The clinical record was reviewed on 05/10/2022 at approximately 1:30 p.m. The admission nursing assessment dated [DATE] contained a base line care plan under skin integrity for Pressure Ulcer. Interventions included: Administer treatments as ordered, monitor dressing to ensure it is intact and adhering . The physician orders were reviewed. There were no orders for treatment of a pressure ulcer. On 05/11/2022 at approximately 8:15 a.m., RN (Registered Nurse) #2 was asked if dressing changes were scheduled for Resident #73. She stated, I stayed over yesterday and got that done so we can get it on the right days .she has a wound vac. The clinical record was reviewed again at approximately 9:00 a.m., and there were no orders observed for the pressure ulcer. At approximately 3:00 p.m., the clinical record was reviewed for some other information, and an order for wound care was observed. The order dated 05/11/2022 with a start date of 05/12/2022 was for the following: Wound Vac to sacrum stage 4 ulcer change Tuesday Thursday and Saturdays. [NAME] foam to be used in tunneling and over bone. Settings 150 one time a day every Tue, Thu, Sat for Stage 4 ulcer. The above information was discussed with the DON (director of nursing) and the administrator on 05/11/2022 at approximately 5:30 p.m. The DON stated that orders for the care of a pressure ulcer should be obtained at the time of admission. On 05/12/2022 at approximately 8:30 a.m., the administrator stated, There was no order for wound care written at the time of admission. She did not have her wound vac on when she came from the hospital we should have gotten orders when she got here but that didn't happen . On 05/12/2022 at approximately 2:15 p.m., RN #2 was interviewed regarding the dressing change that she did on the afternoon of 05/10/2022 and what orders she had followed. She stated, Nobody got any orders when she got her .the wound vac came with her from the hospital but nobody got orders for it or put it on her .the nurse practitioner came in on Tuesday and said we needed to get it on her and she gave me orders then .I put the wound vac on that afternoon I got busy and forgot to put the orders in until the next day (05/11/2022). No further information was obtained prior to the exit conference on 05/19/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate MDS (minimum data set) assessment for two of 22 residents in the survey sample, Resident # 84 and # 76. 1. Resident # 84, was coded in the electronic medical record (EMR) as discharged to an acute hospital, when the resident actually transferred to another facility. 2. Resident # 76 did not have sections C, D, and Q completed of the MDS. Findings include: 1. Resident # 84 was admitted to the facility with diagnoses to include, but not limited to: acute respiratory failure and high blood pressure. On 5/12/22 at 7:45 a.m. the clinical record was reviewed. A review of the progress notes dated 4/25/22 revealed facility staff faxed copies of medications, and prescriptions to the receiving nursing facility, as well as reporting to the nurse receiving the patient. The notes documented the resident had requested to be transferred to a nursing facility closer to family. The discharge MDS (minimum data set) dated 4/25/22 had Section A0310 Type of Discharge left blank with no code for a planned or unplanned discharge. Section A2100 Discharge Status was coded at 3. Acute hospital. The ADON (assistant director of nursing) had informed the survey team earlier in the survey process that the facility did not currently have an MDS coordinator as that employee had left 5/6/22. Therefore, an interview was unable to be conducted with MDS staff. The administrator, DON (director of nursing), and DON from a sister facility were informed of the above findings 5/12/22 at approximately 8:15 a.m. No further information was provided prior to the exit conference.2. Resident #76 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), respiratory failure, heart failure, atrial fibrillation, diabetes, chronic kidney disease, hypertension, anemia, benign prostatic hyperplasia, mood disorder, urine retention, dementia with behavioral disturbance and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #76 with moderately impaired cognitive skills. Resident #76's clinical record documented a quarterly MDS assessment dated [DATE]. Section C (cognitive patterns/brief interview for mental status), section D (mood) and section Q (participation and goal setting) of this MDS were not completed and were marked as not assessed. On 5/11/22 at 4:03 p.m., the director of nursing (DON) was interviewed about the incomplete MDS. The DON stated the social worker was responsible for completing sections C, D and Q on the MDS. On 5/11/22 at 4:10 p.m., the social worker (other staff #7) was interviewed about the incomplete MDS. The social worker stated the sections were incomplete mostly likely because the assessments were not done prior to the assessment reference date. The social worker stated she was recently hired and was still learning about MDS completion. Pages C-2 and D-2 of The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (version 1.17.1 October 2019) documents concerning assessment of cognitive patterns (section C) and mood (section D), Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. This manual documents on page Q-2 concerning assessment participation and goal planning (section Q), .Review the medical record for documentation that the resident, family member and/or significant other, and guardian or legally authorized representative participated in the assessment process .Ask the resident, the family member or significant other (when applicable), and the guardian or legally authorized representative (when applicable) if he or she actively participated in the assessment process . Ask staff members who completed the assessment whether or not the resident, family or significant other, or guardian or legally authorized representative participated in the assessment process . This finding was reviewed with the administrator and director of nursing during a meeting on 5/12/22 at 8:15 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 22 residents, Resident #47. Resident #47 fell at the facility on 04/01/2022 resulting in a large hematoma to her left hip. Her care plan was not revised to include treatment of the area. Findings were: Resident #47 was admitted to the facility with the following diagnoses, including but not limited to: Alzheimer's disease, diabetes mellitus, hypertension, history of falling and conduct disorder. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/18/2022 assessed Resident #47 as severely impaired with a cognitive summary score of 00. Review of the clinical record beginning on 05/10/2022 revealed that Resident #47 had sustained fall on 04/01/2022 resulting in a large hematoma to her left hip: 4/1/2022 19:09 (7:09 p.m.) .CNA .told writer that pt (patient) fell in hallway w (with)/ herself and np (nurse practitioner). She described it as her falling to her knees, rolling side to side like a seizure. Pt was placed to bed by cna and np. Writer was putting in orders at nursing station when pt comes crying in pain. Writer asked where her pain was and she was rubbing her left hip and hollering, Send me to the .hospital. I offered pt standing order tylenol and she slams her hands down on the desk cursing at staff. She charged at myself and cna. Writer notified np and she came to evaluate and found pts left hip to be severely swollen. She ordered for pt to be sent to hospital. Pt was sent w/ ems @ (at) 1600 (4:00 p.m.) . NP Note: Date of Service: 04/15/2022 . On 04/01/2022, the patient was admitted to (Hospital name) for having several falls with severe pain on especially her left hip .CT of the pelvis showed no evidence of fracture or subluxation, however, bilateral subcutaneous hematomas lateral to the proximal femur bilaterally, left greater than the right. Soft tissue hematoma on the left measures 9.3 cm x 4.8 cm x 6 cm The hospital Discharge summary dated [DATE]: Discharge Diagnoses: Fall .has had numerous falls since risperadol was increased to 0.5 bid (twice a day), reduce to 0.25 bid .Traumatic hematoma of left hip .resolving .Summary of Hospital Course: Patient had an unwitnessed fall at the nursing facility .significant pain in the left hip and she is unable to stand or bear weight .normally up and walking around through the day so she was sent to the ER for further evaluation .no fractures or dislocations however she does have a significant hematoma on the left hop and was initially unable to weight bear . NP note on 05/09/2022: .On assessment today, the patient repeatedly is asking for pain medication. On exam, noticed her left hip hematoma has hardened and it is somewhat decreased in size, however, the consistency has changed to a more firm consistency of about the size of a lemon. The patient is complaining about pain and pointing to her hip as she is nearly nonverbal due to word salad. The patient had several emotional outbursts over the weekend that may well be related to her pain . The care plan was reviewed. The focus area for falls contained the following entry: 4/1/2022 Hematoma hip sent to ED/Hosp. Plan is decrease in Risperadal. The DON (director of nursing) was in the conference room on 05/11/2022 at approximately 12:23 p.m. The above information was discussed. She was asked about the care and treatment of the hematoma on Resident #47's hip. She stated, A surgeon saw her and the nurse practitioner is following her. She was asked if the staff should be doing anything with the hematoma or documenting anything. She stated, There should be weekly skin assessments on it. She was asked what the expectation was regarding documentation/assessment of the hematoma. She stated, It should be assessed weekly with measurements, the color, whether or not it is firm, and if there is any pain. She was asked if interventions regarding the hematoma should be on the care plan. She stated, Yes. A facility policy: Non-Pressure Injury/Ulcer Management contained the following: The nursing facility will ensure systems and processes to assist in the identification, investigation, treatment, and care of residents with non-pressure injury related wounds .A resident centered care plan will be developed and implemented to address the resident's wound including interventions to promote healing and to minimize worsening . No further information was obtained prior to the exit conference on 05/19/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of twenty-two residents in the survey sample, Resident #9. Resident #9 eloped from the facility without staff knowledge and/or supervision. Nursing made no record of the incident, documented no assessment of the resident when found, and made no notification to administration, the provider or family about the incident. The findings include: Resident #9 was admitted to the facility with diagnoses that included vascular dementia with behavioral disturbance, vitamin D deficiency, major depressive disorder, hypothyroidism, atherosclerotic heart disease, benign prostatic hyperplasia, hypertension and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #9 with severely impaired cognitive skills. On 5/10/22 at 2:18 p.m., Resident #9's family member was interviewed about quality of care in the facility. The family member stated the resident was found several days ago by hospital staff wandering in the adjacent hospital without supervision. The family member stated she heard this from a person that did not work for the facility and thought the resident's Wanderguard device was not working. Resident #9's clinical record for May 2022 made no mention of any elopement incidents. On 5/11/22 at 11:13 a.m., the licensed practical nurse (LPN) #2 caring for Resident #9 was interviewed about any recent elopements. LPN #2 stated it was communicated during shift report that Resident #9 was found by hospital staff and brought back to the facility. LPN #2 stated this happened in the last couple of weeks but she did not know the date of the incident. On 5/11/22 at 11:33 a.m., the director of nursing (DON) was interviewed about Resident #9's elopement. The DON stated she heard about the incident in the stand-up meeting on Monday (5/9/22). The DON stated the incident was not reported to the administrator, physician or family. The DON stated the incident should have been reported and documented when it occurred. On 5/11/22 at 3:00 p.m., the administrator was interviewed about the elopement incident with Resident #9. The administrator stated the resident's daughter called her yesterday (5/10/22) and reported she heard the resident was found in the adjacent hospital. The administrator stated she had not been notified by facility staff about the incident. The administrator stated the incident happened on 5/8/22 with LPN #3 working. The administrator stated she had not yet talked with LPN #3 about the details of the incident. On 5/12/22 at 9:43 a.m., LPN #3 that cared for Resident #9 on 5/8/22 was interviewed. LPN #3 stated she was administering medications during the evening shift on 5/8/22 when a therapist and another hospital employee brought Resident #9 back to the unit. LPN #3 stated the hospital staff found the resident wandering on the medical-surgical unit of the hospital which is on the connecting floor to the facility. LPN #3 stated the incident occurred between 8:00 p.m. and 10:00 p.m. LPN #3 stated she did not call the family because it was late and did not notify the physician and/or provider because the resident was not hurt. LPN #3 stated she did not document the incident in the resident's clinical record. LPN #3 stated, I should have made a note. LPN #3 stated she assessed the resident after the incident, found no injuries but did not document the assessment. The facility's policy titled Elopement/Missing Person (undated) documented, .It is the responsibility of all staff members to report immediately to the administrator or DON or Nursing Supervisor, and resident attempting to leave the premise or is suspected of not being on the premises without properly checking out in accordance with established policy and procedures . (sic) This policy documented, .Upon return of the resident to the facility, or upon finding the resident, the following steps shall be carried out .The resident will be evaluated by a licensed nurse and/or physician/practitioner .At a minimum the resident's vital signs will be taken, the resident's cognitive and behavioral status will be reviewed, and a full body evaluation will be done to identify any injury incurred. These findings shall be communicated to the physician for further instruction and documented in the clinical record .The resident's medical record will document the details of the event, including evaluation of the resident, treatment/care provided, and monitoring of the resident . The Lippincott Manual of Nursing Practice 11th edition documents on page 15 concerning standards of practice, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events .Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion .follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review, and staff interview, the facility staff failed to ensure a complete and accurate record for two of 22 residents in the survey sample, Resident # 80 and # 238. 1. Resident # 80 had weights inaccurately recorded. 2. Resident # 238 did not have a code status documented. Findings include: 1. Resident # 80 was admitted to the facility with diagnoses to include, but not limited to: stroke, peripheral artery disease, high blood pressure, and dysphagia following a stroke. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had Resident # 80 coded with moderate impairment in cognition with a score of 04 out of 15. The clinical record was reviewed 5/11/22 beginning at 8:00 a.m. The following weights were recored for Resident # 80: 4/27/22 (admission weight)- 204.3 via weight chair. 5/2/22- 254.4 sitting (this weight was crossed out with staff documentation Wrong chart.) 5/2/22- 254.2 via weight chair 5/9/22- 145.4 via weight chair On 5/11/22 at 8:51 a.m. the ADON (assistant director of nursing) was asked about the weight discrepancies, and if the facility registered dietitian or dietary manager was aware of the weights. The ADON stated We haven't had a dietitian for approximately 4 to 6 weeks. I don't know if the dietary manager is aware as the DON (director of nursing) is in charge of the weights. There was education provided to the CNAs (certified nursing assistant) to weigh residents the same way for consistency. On 5/11/22 at 10:00 a.m. the facility's family nurse practitioner (FNP) was interviewed and asked about Resident # 80's weights. The FNP reviewed the weights for the resident and stated No one has made me aware of this. That's a pretty big discrepancy. I am going to ask staff to reweigh her now and see if we can establish what her weight actually is. The policy entitled: Weight Assessment and Intervention under Specific Procedures/Guidance at # 3 directed If an inaccurate weight is suspected, the resident will be reweighed according to facility policy. On 5/11/22 at 11:15 a.m. the DON was asked about weights for residents, and if staff were to notify her as she had been identified as being in charge of weights. The DON stated, If a weight is five pounds less or more than the previous recorded weight, the resident is to be reweighed using the same scales, same method, to observe any variance. The weight variances are then discussed at morning meeting and the dietary manager also attends. The DON was asked if Resident # 80 had been part of any discussion about weights. The DON stated No, I was not aware of the weights for her. The administrator, DON (director of nursing), and DON from a sister facility were informed of the above findings 5/12/22 at approximately 8:15 a.m. No further information was provided prior to the exit conference. 2. Resident # 238 was admitted to the facility with diagnoses to include, but were not limited to: Non-alcoholic steatohepatitis (NASH), asthma, diabetes, and high blood pressure. There was no MDS (minimum data set) information as the resident was newly admitted less than fourteen days. On 5/10/22 at approximately 1:00 p.m. Resident # 238 was interviewed and asked about any advance directives. Resident # 238 stated she had not fully decided, and had thought of declaring DNR (do not resuscitate), but then added I have a lot I want to do yet, so I'm not sure I want to do that. The code status for Resident # 238 was not documented in the EMR. The code status was also not located in the paper chart, and OS (other staff) # 6 was asked for assistance. OS # 6 retrieved the chart, opened it and stated The code status is here under the 'purple' tab . She lifted the tab and stated You're right, there's nothing there .admissions usually gets that from the d/c (discharge) summary from where they came in from . There was also no code status identified on the hospital discharge summary. OS # 6 stated, Until we get a signed DNR, they are supposed to be a full code. The administrator, DON (director of nursing), and DON from a sister facility were informed of the above findings 5/12/22 at approximately 8:15 a.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide records of weekly hospice visits as required in the hospice services agreement, for one of 22 residents in the [NAME] sample, Resident #51. The findings include: Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section O - Special Treatments, Procedures, and Programs, Resident #51 was assessed as receiving Hospice services. Resident #51's electronic health record (EHR) was reviewed on 05/10/22. Observed within the order summary was an order for hospice care dated 04/07/2022. Observed within the miscellaneous section of the EHR were hospice notes dated 04/26/22, 04/27, 22 and 04/28/22. On 05/11/2022 Resident #51's paper chart was reviewed. Observed within the paper chart was the initial hospice assessment and plan dated 04/07/222, and hospice notes dated 04/20/22. On 05/11/2022 at 9:15 a.m., the DON was interviewed regarding the hospice services. The DON stated, Hospice comes weekly, we never know when they're coming. They usually fax us the notes after they come. On 05/11/2022 at 11:30 a.m., the DON was asked about how hospice communicated their findings and/or concerns with the facility's staff. The DON stated, We've had some problems and have talked to them about the lack of communication between the hospice staff and our staff. Sometimes they will come in for a visit and leave without speaking to any of the nursing or social work staff. The DON was advised of the limited amount of hospice notes available in both Resident #51's electronic and paper records. A review of the Nursing Home Agreement For Provision Of Hospice Services signed on 10/29/2021 between the facility and hospice provider documented on page 8 the following: . 4. Records: 4/1 Compilation of Records: 4/1/1: Preparation: The Nursing Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving Nursing Facility Services and Hospice Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state law and regulations and application Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Residential Hospice Patient (including evaluations, treatments, progress notes, authorizations to admissions to Hospice and/or the Nursing Facility and physician orders, entered pursuant to the Agreement). The Nursing Facility and Hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services The above findings were reviewed with the administrator and director of nursing during a meeting on 05/11/2022 at 5:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #188 was admitted to the facility with the following diagnoses, including but not limited to: Displaced bimalleolar fracture of right lower leg, hypo-osmolality and hyponatremia, osteoarthritis, hypertension, hypothyroidism, and cerebral infarction. Due to Resident #188's recent admission there was no MDS (minimum data set) assessment completed. An admission nursing assessment was not done and the admission nursing note dated 05/06/2022 did not discuss Resident #188's cognitive status. While speaking with Resident #188 during initial tour of the facility on 05/10/2022 at approximately 11:15 a.m., she was awake, alert, and oriented to her name, place and situation. Resident #188 was interviewed on 05/11/2022 at approximately 10:50 a.m. Her care at the facility was discussed and she was asked if she had received a copy of a baseline care plan outlining the care and services at the facility. She stated, No, I didn't get anything like that. The clinical record was reviewed on 05/11/2022 at approximately 11:15 a.m. The physician orders included but were not limited to: 1200 ml fluid restriction every shift; NWB (non weight bearing) right lower extremity, Monitor and document pain level. The baseline care plan made no mention of Resident #188's pain management, NWB status due to a broken ankle, or of fluid restrictions. During an end of the day meeting with the DON (director of nursing) and the administrator on 05/11/2022 at approximately 5:30 p.m., the above information was discussed. The DON was asked if pertinent information such as fluid restrictions, pain management, and weight bearing status, should be on the baseline care plan. She stated, Yes. No further information was obtained prior to the exit conference on 05/19/2022. 3. Resident #73 was admitted to the facility with the following diagnoses including but not limited to: osteoarthritis, hypertension, morbid obesity, acute respiratory failure, diabetes mellitus, and Stage IV Sacral pressure ulcer. Due to her recent admission there was no MDS (minimum data set) assessment. According to her admission assessment dated [DATE], she was oriented to person, place, time, and situation. Initial tour was conducted at approximately 10:45 a.m. on 05/10/2022. RN (registered nurse) #2 was observed in Resident #73's room giving medications. She was wearing only a surgical mask. A sign beside the door read Contact Precautions. When RN #2 exited the room she was asked why Resident #73 was on contact precautions. She stated, She is a new admission, she's not vaccinated .we put them on precautions for ten days after they get here .she should be on droplet precautions not contact precautions. She went over to the doorway and removed the sign reading contact precautions and hung one up for droplet precautions. The clinical record was reviewed at approximately 1:30 p.m., on 05/10/2022. There was no mention of Resident #73 being on any type of transmission based precautions. The base line care plan was reviewed. There were no interventions/problems listed regarding the need for any type of isolation. . An end of the day meeting was held on 05/11/2022 with the DON (director of nursing) and the administrator. The above information was discussed. The DON was asked if interventions regarding droplet precautions should be on Resident #73's baseline care plan. The DON stated, Yes. On 05/12/2022 at 8:15 a.m., the administrator and the DON came to the conference room to present information. Per the administrator, Resident #73 was tested for COVID prior to leaving the hospital and was negative. She was placed on droplet precautions due to her nonvaccinated status. She stated, The order for precautions should have been obtained at the time of the admission and it should have been on her baseline care plan. No further information was obtained prior to the exit conference on 05/19/2022. Based on staff interview, clinical record review, resident interview, and facility document review, the facility staff failed to develop a baseline care plan for three of 22 residents in the survey sample, Resident # 238, # 188, and # 73. 1. Resident # 238 did not a care plan for NASH (non-alcoholic steatohepatitis). 2. Resident # 188 did not have a baseline care plan for pain related to a fractured ankle, and also did not receive a copy of the baseline care plan. 3. Resident # 73 did not have a baseline care plan for droplet precautions. Findings include: 1. Resident # 238 was admitted to the facility with diagnoses to include, but were not limited to: Non-alcoholic steatohepatitis (NASH), asthma, diabetes, and high blood pressure. There was no MDS (minimum data set) information as the resident was newly admitted less than fourteen days. On initial interview 5/10/22 at approximately 1:00 p.m. the resident conversed appropriately and appeared to be extremely cognitive. The clinical record was reviewed 5/10/22 beginning at 11:00 a.m. The base line care plan did not include interventions for the resident's NASH. On 5/11/22 at 11:15 a.m. The DON (director of nursing) was interviewed. She was made aware there was no baseline care plan to address the resident's medical condition of NASH, and no care plan for the resident's desire of discharge. The DON stated there should have been a care plan for NASH as fluid builds up in the abdomen and should be monitored for any change needing interventions to drain the fluid. A policy for the development of a base line care plan was requested. The policy Baseline Care Plans included Specific Procedures/Guidance. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The interdisciplinary team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc) and implement the baseline care plan to meet the resident's immediate care needs .3. The baseline care plan will be used until staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. The administrator, DON(director of nursing), and DON from a sister facility were informed of the above findings 5/12/22 at approximately 8:15 a.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 5 of 22 residents in the survey sample, Residents #62 #51, #6, #70, and #76. Resident #62's CCP did not include a focus areas with goals and interventions for the use of an anticoagulant. Resident #51's CCP did not include a focus area with goals and interventions for hospice care. Resident #6's CCP did not include a focus area with goals and interventions for nutritional/dietary needs. Resident #70's CCP did not include a focus area with goals and interventions for palliative care. Resident #76's CCP did not include a focus area with goals and interventions for mood disorder and behaviors. The findings include: 1. Resident #62 was admitted to the facility with diagnoses that included atrial fibrillation, congestive heart failure, bipolar disorder, above knee amputation, history of fails, hyperkalemia, type 2 diabetes, hypothyroidism, and heart failure. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #62 as moderately cognitively impaired with a score of 10 out of 15. Under Section N - Medications, the MDS assessed Resident #62 as receiving anticoagulant medications. Resident #62's electronic health record (EHR) was reviewed on 05/11/2022. Observed on the order summary report was the following: Rivaroxaban Tablet 20 MG. Give 20 mg by mouth in the evening for anticoagulant. Order/Start Date: 01/20/2022. A review of Resident #62's medication administration record (MAR) for the period of January 2022 through May 2022 documented Resident #62 received the anticoagulant medication as ordered. Resident #62's CCP did not include the use of Rivaroxaban (Xarelto) anticoagulant medication. On 05/11/2022 at 9:00 a.m., the licensed practical nurse (LPN) #2 who routinely provided care for Resident #62 was interviewed. LPN #2 reviewed Resident #62's order summary and MAR and stated the resident remained on the anticoagulant medication. LPN #2 was asked who was responsible for the care plans. LPN #2 stated the facility had to hire a new MDS coordinator and to speak with the DON regarding the care plan development. On 05/11/2022 at 9:15 a.m., the DON was interviewed about Resident #62's CCP. The DON stated there should have been a care plan developed when the medication was ordered and started. The DON stated she could not speak to why a care plan was not developed back in January 2022 when the medication was started. The above findings were reviewed with the administrator and director of nursing during a meeting on 05/11/2022 at 5:30 p.m. 2. Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section O - Special Treatments, Procedures, and Programs, Resident #51 was assessed as receiving Hospice services. Resident #51's electronic health record (EHR) was reviewed on 05/10/22. Observed within the order summary was an order for hospice care dated 04/07/2022. Observed within the miscellaneous section of the EHR were hospice notes dated 04/26/22, 04/27, 22 and 04/28/22. On 05/11/2022 Resident #51's paper chart was reviewed. Observed within the paper chart was the initial hospice assessment and plan dated 04/07/2022, and hospice notes dated 04/20/22. A review of Resident #51's care plans did not include a hospice specific care plan. On 05/11/2022 at 9:15 a.m., the DON was interviewed regarding the hospice care plan. The DON stated there should have been a hospice care plan developed at admission. The above findings were reviewed with the administrator and director of nursing during a meeting on 05/11/2022 at 5:30 p.m. 3. Resident #6 was admitted to the facility with diagnoses that included chronic pain, dysphasia, peripheral vascular disease, hypertension, congestive heart failure, gastro-esophageal reflux disease (GERD), muscle weakness, and glaucoma. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed Resident #6 as moderately cognitively impaired with as score of 9 out of 15. Section V - Care Area Assessment triggered for a nutritional care plan. Resident #6's electronic health record (EHR) was reviewed on 05/11/2022. Observed on the order summary report was the following: Regular Diet - Regular texture, Regular/Thin consistence NDD4 (dysphasia) with chopped meats and gravy. patient requested mashed potatoes instead of baked potatoes due to difficulty chewing skin. Order Date: 12/13/2021. Start Date: 12/15/2021. Observed in the EHR was a nutritional assessment dated [DATE]. The nutritional assessment documented Resident #6 with GERD and dysphasia diagnoses and at risk for malnutrition related to being underweight and having a goal to have a slow weight gain over the next 90 days. A review of Resident #6's care plans did not include a nutritional/dietary care plan. On 05/11/2022 at 9:15 a.m., the DON was interviewed about Resident #6's care plans. The DON stated someone from corporate was helping with the care plans and there should have been a nutritional care plan completed for Resident #6. The above findings were reviewed with the administrator and director of nursing during a meeting on 05/11/2022 at 5:30 p.m. On 05/12/2022 at 7:20 a.m. the administrator stated she had reviewed Resident #6's record and he was seen by speech upon admission. The administrator stated there should have been a nutritional/dietary care plan on file and it was not completed.4. Resident #70 was admitted to the facility with diagnoses that included Alzheimer's disease, diabetes, glaucoma, atrial fibrillation, hypertension, vascular dementia and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #70 with severely impaired cognitive skills. Resident #70's clinical record documented a physician's order dated 12/13/21 for palliative care related to the Alzheimer's diagnosis with instructions for no labs, no intravenous sticks/fluid, no intake/output monitoring and no glucose monitoring. Resident #70's plan of care (revised 4/27/22) included no problems, goals and/or interventions regarding palliative care. On 5/11/22 at 6:20 p.m., the director of nursing (DON) was interviewed about a palliative care plan for Resident #70. The DON stated a plan of care for palliative care/services should have been developed for Resident #70. This finding was reviewed with the administrator and director of nursing during a meeting on 5/12/22 at 8:15 a.m. 5. Resident #76 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), respiratory failure, heart failure, atrial fibrillation, diabetes, chronic kidney disease, hypertension, anemia, benign prostatic hyperplasia, mood disorder, urine retention, dementia with behavioral disturbance and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #76 with moderately impaired cognitive skills. Resident #76's clinical record documented a physician's order dated 4/15/22 for the antipsychotic medication Seroquel 50 mg (milligrams) administered at each bedtime for mood disorder. Resident #76's plan of care (revised 4/27/22) included no problems, goals and/or interventions regarding the resident's mood disorder or behaviors related to mood. On 5/12/22 at 8:56 a.m., the licensed practical nurse (LPN #2) caring for Resident #76 was interviewed. LPN #2 stated the resident sometimes hallucinated, hearing and seeing people in his room that were not there. LPN #2 stated Resident #76 at times refused care and made verbal outbursts. LPN #2 stated she was not sure why the care plan did not include the resident's behaviors related to his mood disorder. LPN #2 stated the unit manager and/or MDS coordinator were responsible for care plans. LPN #2 stated there was currently no unit manager on Resident #76's unit and no MDS coordinator for the facility. This finding was reviewed with the administrator and director of nursing during a meeting on 5/12/22 at 8:15 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 22 residents in the survey sample, Residents #6, #62, #188, and #33; and failed to assess and monitor a left hip hematoma for one of 22 in the survey sample, Resident #47. Resident #6 did not have Debrox drops administered as ordered. Resident #62 did not have prophylactic medications administered as ordered. Resident #188 did not have fluid intake monitored for compliance with fluid restriction as ordered. Resident #47 did not have a hematoma monitored. Resident #33 did not have the medication Abilify administered as ordered. The findings include: 1. Resident #6 was admitted to the facility with diagnoses that included chronic pain, dysphasia, peripheral vascular disease, hypertension, congestive heart failure, gastro-esophageal reflux disease (GERD), muscle weakness, and glaucoma. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed Resident #6 as moderately cognitively impaired with as score of 9 out of 15. On 05/10/2022 during the initial tour Resident #6 was interviewed. During the interview, Resident #6 was observed leaning in with his right ear and saying, Huh, I'm hard of hearing. Can you write down what you're saying on that white board. Resident #6's EHR documented the resident was seen by the facility's nurse practitioner (NP) on 04/28/2022 for complaints of dizziness. The NP's progress note documented, .He is extremely hard of hearing and had a recent audiology exam. He is currently not wearing his hearing aid which he believes does not work although new batteries were just inserted. Otoscopic (ear canal) exam was made difficult by patient's heightened sensitivity to touch. Observed cerumen (wax) buildup Plan: Debrox treatment as per standing orders for cerumen impaction . 5/3/2022 Debrox Solution Instill 4 drop in left ear at bedtime for ear wax impaction for 4 Days on the 5th night irrigate with NS (normal saline) and notify provider med is not here yet. 5/4/22 Debrox Solution Instill 4 drop in left ear at bedtime for ear wax impaction for 4 Days on the 5th night irrigate with NS (normal saline) and notify provider waiting on pharmacy. 5/5/22 Debrox Solution Instill 4 drop in left ear at bedtime for ear wax impaction for 4 Days on the 5th night irrigate with NS (normal saline) and notify provider med reordered. 5/6/22 Debrox Solution Instill 4 drop in left ear at bedtime for ear wax impaction for 4 Days on the 5th night irrigate with NS (normal saline) and notify provider med is not here. A review of the medication administration record (MAR) for the month of May did not evidence that Resident #6 received the Debrox solution as per standing orders from the NP on 04/28/2022. On 05/11/2022 the licensed practical nurse (LPN) #2 who routinely provided care for Resident #6 was interviewed regarding why the Debrox solution was not administered to the resident. LPN #2 stated Resident #6 was very hard of hearing and wore his hearing aide in his right ear only, but sometimes he would refuse to wear it and/or remove it because he didn't believe it worked. LPN #2 reviewed the EHR stated she was not aware of situation with Debrox solution and maybe the DON could provide more information. On 05/11/2022 at 9:15 a.m., the DON was interviewed regarding the availability of the Debrox solution. The DON stated the facility had some issues with the pharmacy delivery. The DON was asked if the medication was ever ordered and/or received because there the clinical record did not document any information about the Debrox solution after 5/6/22. The DON was asked if the nurse practitioner was notified the Debrox solution was not administered. The DON stated, I'm not sure, we've identified some documentation problems. I honestly can't say if the nurses notified the NP or not and they just didn't document. On 05/11/2022 at 5:30 p.m., the facility's administrator stated the Debrox solution was a house stock item and was currently in stock at the facility. The administrator stated the solution was not ordered through the pharmacy, only notes were placed in the EHR. The administrator stated the house stock list had changed and staff were not aware of all of the changes. The administrator stated the facility was going to follow-up with the nurse NP to see if the Debrox solution was still needed. On 05/12/2022 at 7:20 a.m., the administrator advised Resident #6 had received the Debrox solution as per standing orders. 2. Resident #62 was admitted to the facility with diagnoses that included atrial fibrillation, congestive heart failure, bipolar disorder, above knee amputation, history of fails, hyperkalemia, type 2 diabetes, hypothyroidism, and heart failure. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #62 as moderately cognitively impaired with a score of 10 out of 15. Resident #62's electronic health record (EHR) was reviewed on 05/10/2022. Observed on the order summary report were the following: Hiprex Tablet (Methenamine Hippurate) Give 1 gram by mouth two times a day for prophylactics and suppression of uti. Order Date: 03/31/2022. Start Date: 04/01/2022. Lactobacillus Capsule Give 1 capsule by mouth two times a day for frequent UTIs. Order/Start Date: 02/09/2022. Resident #62's EHR including the medication administration record (MAR) for the month of May 2022 documented Resident #62 missed the Hiprex morning doses on 5/7/2022, 5/8/2022, 5/9/2022, and 5/10/2022; and missed the Hiprex evening doses on 5/6/2022, 5/7/2022, 5/8/2022, 5/9/2022, and 5/10/2022. The progress notes documented the Hiprex was on order from the pharmacy. The EHR and MAR documented Resident #62 missed the Lactobacillus evening doses on 5/5/2022 and 5/6/2022. The progress notes documented the medication was unavailable because it was locked in the refrigerator and staff did not have a key to the refrigerator. On 05/11/2022 at 8:45 a.m., the licensed practical nurse (LPN) #2 who routinely provided care for Resident #62 was interviewed about the missed doses of medications. LPN #2 stated, We didn't have a key to the refrigerator where the Lactobacillus was stored, that is why it was missed. I notified the DON and she provided us with a key on this floor. The Hiprex medication was on order from the pharmacy. We've had some problems with the pharmacy deliveries being late or having to send multiple order requests. I did check the med cart and that medication came in late last night or early this morning and I will administer it this morning. LPN #2 was asked if the nurse practitioner was notified about the missed doses. LPN #2 reviewed the EHR and stated, I was off a few days and looking at the record I don't believe she was notified. We probably should notify her of these problems. On 05/11/2022 at 9:15 a.m., the DON was interviewed about the missed doses. The DON stated a new lock was recently placed on the medication refrigerator and some of the staff were not provided a key for the new lock. The DON stated when LPN #2 advised her Resident #62 missed doses of the Lactobacillus due to it being locked in the refrigerator she immediately provided LPN #2 with a key. The DON was asked about the missed Hiprex doses. The DON stated the facility was having an issue with the pharmacy delivery because it was located in North Carolina. The DON was asked if staff had notified the NP about the missed doses. The DON stated, I'm not sure, we've identified some documentation problems. I honestly can't say if the nurses notified the NP or not and they just didn't document it. The DON was asked if the Hiprex was located in the Omnicell medication dispensing unit. On 05/11/2022 at 5:30 p.m. the above findings were reviewed with the administrator and director of nursing. The DON stated the Hiprex medication was not available for dispensing in the Omnicell. The DON was asked what was the expectation regarding notification of missed medication. The DON stated nursing should have notified the provider to see if an alternate medication could be prescribed and to notify herself and/or the administrator if there was a continuing problem with the pharmacy. On 05/11/2022 at 7:20 a.m., the administrator advised the NP was notified of the missed medication on 05/11/2022.3. Resident #188 was admitted to the facility with the following diagnoses, including but not limited to: Displaced bimalleolar fracture of right lower leg, hypo-osmolality and hyponatremia, osteoarthritis, hypertension, hypothyroidism, and cerebral infarction. Due to Resident #188's recent admission there was no MDS (minimum data set) assessment completed. An admission nursing assessment was not done and the admission nursing note dated 05/06/2022 did not discuss Resident #188's cognitive status. While speaking with Resident #188 on 05/10/2022 at approximately 11:15 a.m., she was awake, alert, and oriented to her name, place and situation. The clinical record was reviewed on 05/11/2022 at approximately 11:15 a.m. The physician orders included but were not limited to: 1200 ml fluid restriction every shift . The baseline care plan was reviewed. There was no mention of fluid restriction. The MAR and TAR (medication administration record/treatment administration record) were reviewed and there were no entries regarding fluid restriction. Resident #188 was interviewed on 5/11/2022 at approximately 4:00 p.m. regarding fluid restriction. She stated, Yes, I am limited, I have ice chips and I limit myself. She was asked if any of the staff were asking her questions regarding the amount of fluids she was consuming per shift or per day. She stated, No, no one is asking me anything about that. LPN (Licensed practical nurse) #4 who was assigned to Resident #188, was interviewed at approximately 4:15 p.m. on 05/11/2022. She was asked if she was aware that Resident #188 was on fluid restriction. She stated, No, I don't think I knew that, let me look at her orders. LPN #4 looked at the MAR, TAR, and physician orders. She stated, I see the order but I don't see it on anything to track it .it's not on the MAR or the TAR. She was asked how she would track it. She stated, I guess I would need to do a progress note I don't know why it isn't on the MAR or the TAR, that's where it should be so we know to be looking at it the order really needs to be clarified .I don't think it is 1200 mls per shift, that's probably per day. During an end of the day meeting with the DON (director of nursing) and the administrator on 05/11/2022 at approximately 5:30 p.m. The above information was discussed. The DON was asked if the nurses should be tracking Resident #188's fluid intake and if so how. The DON was also asked whether or not the order needed clarification. She stated, If she is on restrictions we should be tracking it every shift. On 05/12/2022 at approximately 8:30 a.m., the administrator stated, The fluid restriction for (Resident #188) were not entered correctly in (electronic medical record), there was no way to track it .we corrected it last night and got it clarified. It should have been 1200 cc per day, not per shift, and now it is on the administration record so they can keep track of it. No further information was obtained prior to the exit conference on 05/19/2022. 4. Resident #47 was admitted to the facility with the following diagnoses, including but not limited to: Alzheimer's disease, diabetes mellitus, hypertension, history of falling and conduct disorder. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/18/2022 assessed Resident #47 as severely impaired with a cognitive summary score of 00. Review of the clinical record beginning on 05/10/2022 revealed that Resident #47 had sustained fall on 04/01/2022 resulting in a large hematoma to her left hip: 4/1/2022 19:09 (7:09 p.m.) .CNA (certified nursing assistant) .told writer that pt (patient) fell in hallway w (with)/ herself and np (nurse practitioner). She described it as her falling to her knees, rolling side to side like a seizure. Pt was placed to bed by cna and np. Writer was putting in orders at nursing station when pt comes crying in pain. Writer asked where her pain was and she was rubbing her left hip and hollering, Send me to the .hospital. I offered pt standing order tylenol and she slams her hands down on the desk cursing at staff. She charged at myself and cna. Writer notified np and she came to evaluate and found pts left hip to be severely swollen. She ordered for pt to be sent to hospital. Pt was sent w/ ems @ (at) 1600 (4:00 p.m.) . The hospital Discharge summary dated [DATE]: Discharge Diagnoses: Fall .has had numerous falls since risperadol was increased to 0.5 bid (twice a day), reduce to 0.25 bid .Traumatic hematoma of left hip .resolving .Summary of Hospital Course: Patient had an unwitnessed fall at the nursing facility .significant pain in the left hip and she is unable to stand or bear weight .normally up and walking around through the day so she was sent to the ER for further evaluation .no fractures or dislocations however she does have a significant hematoma on the left hop and was initially unable to weight bear . The readmission assessment to the facility on [DATE] made no mention of the hematoma on the assessment. NP Note: Date of Service: 04/15/2022 .On 04/01/2022, the patient was admitted to (Hospital name) for having several falls with severe pain on especially her left hip .CT of the pelvis showed no evidence of fracture or subluxation, however, bilateral subcutaneous hematomas lateral to the proximal femur bilaterally, left greater than the right. Soft tissue hematoma on the left measures 9.3 cm x 4.8 cm x 6 cm . NP note dated 04/22/2022: On assessment today, conferred with wound care physician who examined the patient's left hip hematoma. Because of the patient's mental condition, we would prefer having that patient seen with sedation by Surgery or the Emergency Room. Called emergency room who declined the patient and called Surgery, (Name) who will see the patient today at 1600 in their office for her left hip hematoma. The patient continues to walk around in the hallway and is upset about something, but cannot express herself . A skin assessment completed on 04/22/2022 contained the following: Patient w/ several scabbed areas scattering her body (face, hands, etc.). Also a large mass located to left hip at this time. NP aware and wound team to come and evaluate. There were no other skin assessments regarding the hematoma. NP note dated 04/25/2022: Please schedule Surgery appointment urgent for left hip hematoma, which is painful, may need surgical evacuation. NP note dated 04/28/2022: On assessment today, the patient does not offer complaints. She visited a general surgeon yesterday, . his office notes stated that the hematoma absorbs naturally and will follow up with him in 2 weeks On 05/09/2022 the NP wrote: On 04/01/2022, the patient was admitted to [NAME] Memorial Hospital for having several falls with severe pain on especially her left hip. In the emergency room .CT of the pelvis showed no evidence of fracture or subluxation, however, bilateral subcutaneous hematomas lateral to the proximal femur bilaterally, left greater than the right. Soft tissue hematoma on the left measures 9.3 cm x 4.8 cm x 6 cm. On assessment today, the patient repeatedly is asking for pain medication. On exam, noticed her left hip hematoma has hardened and it is somewhat decreased in size, however, the consistency has changed to a more firm consistency of about the size of a lemon. The patient is complaining about pain and pointing to her hip as she is nearly nonverbal . The patient had several emotional outbursts over the weekend that may well be related to her pain . RN (Registered Nurse) #2 was interviewed on 05/11/2022 at approximately 11:30 a.m. regarding Resident #47's hematoma. She was asked if she had completed any skin assessments or measurements of the area. She stated, No. The DON (director of nursing) was interviewed on 05/11/2022 at approximately 12:23 p.m. She was asked about the care and treatment of the hematoma on Resident #47's hip. She stated, A surgeon saw her and the nurse practitioner is following her. She was asked if the staff should be doing anything with the hematoma or documenting anything. She stated, There should be weekly skin assessments on it. She was asked about the expectation for documentation/assessment of the hematoma. She stated, It should be assessed weekly with measurements, the color, whether or not it is firm, and if there is any pain. A facility policy: Non-Pressure Injury/Ulcer Management contained the following: The nursing facility will ensure systems and processes to assist in the identification, investigation, treatment, and care of residents with non-pressure injury related wounds .Evaluation/assessment of non-pressure injury wounds will be completed weekly with significant change in condition of the ulcer/injury by a licesnsed nurse and/or practitioner. On 05/12/2022 at approximately 8:30 a.m., the following note was observed regarding the hematoma: 5/11/2022 14:08 (2:08 p.m.) Skin Evaluation: .Resident has current skin issues. Skin Issue: Bruising. Skin issue location: Left hip Length: 1.5 Width: 1.0 Tissue: Painful. Tissue: Firm. Skin Issue: .Hard hematoma .Location: Left hip. Length: 4.0 Width: 2.0 Tissue: Painful. Tissue: Firm .Skin note: Hematoma continues on left hip. Small resolving bruise top of hematoma. Area firm to touch and painful. Has follow-up surgical appointment on 5/20/2022 . No further information was obtained prior to the exit conference on 05/19/2022. 5. Resident #33 was admitted to the facility with diagnoses that included multiple sclerosis, hyperlipidemia, insomnia, major depressive disorder, morbid obesity, anxiety, polyneuropathy, hypertension, chronic pain syndrome, overactive bladder and obstructive sleep apnea. The minimum data set (MDS) dated [DATE] assessed Resident #33 as cognitively intact. Resident #33's clinical record documented a physician's order dated 12/15/21 for the medication aripiprazole (Abilify) 100 mg (milligrams) to be administered each day for treatment of major depressive disorder. Resident #33's medication administration record (MAR) for April 2022 documented the Abilify was not administered as ordered on 4/14/22, 4/15/22, 4/18/22, 4/23/22, 4/25/22 and 4/26/22. Nursing notes dated 4/14/22, 4/18/22, 4/23/22 and 4/26/22 documented the Abilify was not available on the medication cart awaiting delivery from the pharmacy. Resident #33's plan of care (revised 4/27/22) documented the resident used psychotropic medications for treatment of depression. Interventions to ensure lowest therapeutic dose included to administer medications as ordered by the physician. On 5/11/22 at 4:03 p.m., the director of nursing (DON) was interviewed about Resident #33's missed medications. The DON stated there had been a lot of trouble with pharmacy. The DON stated the pharmacy was located out of state and orders/refills sent in after 4:00 p.m. were not processed until the next day. The DON had no explanation how the medication was marked as administered on 4/16/22, 4/1722 and 4/24/22 when the medication was not available. On 5/12/22 at 9:15 a.m., the administrator stated Resident #33's Abilify was not here to give. The administrator stated Abilify was not available in the stocked emergency supply. The Nursing 2022 Drug Handbook on page 144 describes Abilify as an antipsychotic medication used as adjunctive treatment of major depressive disorder. (1) This finding was reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Resident #11 was admitted to the facility with diagnoses that included difficulty walking, stage 4 pressure ulcer to sacral region, vascular dementia without behaviors, type 2 diabetes, dysphasia, hypertension, hypothyroidism, hyperlipidemia, anemia, Vitamin D deficiency, and cerebral aneurysm. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #11 as severely cognitively impaired with a score of 5 out of 15. Resident #11's clincial record was reviewed on 05/10/22. Observed on the order summary report was the following: Cleanse sacral wound with wound cleanser, pack with lodofoam, wet with lidocaine/morphine, cover with foam dressing in the evening for wound care. Order/Start Date: 04/14/2022. Resident #11's clinical record documented the most recent skin evaluation was completed on 03/15/2022 and the most recent wound evaluation was on 04/28/2022. On 05/11/2022 at 8:45 a.m., the licensed practical nurse (LPN) #2 who routinely provided are for Resident #11 was interviewed about the resident's current skin conditions and wound evaluations. LPN #2 stated, She still has a wound on her sacrum. It's small and the dressing change is done on the evening shift. There is a wound provider that comes weekly, but I'm not sure of the exact day. LPN #2 was asked how skin evaluations were completed. LPN #2 reviewed Resident #11's clinical record and stated, Well the last one here is on March 15 and the system is showing the next skin eval was past due on March 22, but they are supposed to be done weekly. LPN #2 was asked why the skin evaluations weren't completed as ordered. LPN #2 stated, I would say because of staffing. This floor has the largest census in the building and med pass. When there is only one nurse on the floor, unfortunately things get missed or put off. On 05/11/2022 at 9:15 a.m., the DON was interviewed regarding the missing skin and wound evaluations. The DON stated the wound care provider visited weekly and the ADON (RN #1) routinely rounded with the wound care provider and had the most recent wound evaluation documentation in a large wound binder. The DON was asked if a separate skin evaluation should be done or was the wound evaluation sufficient. The DON stated, No the skin and would evaluations are separate. Everyone gets a weekly skin eval. They receive a wound eval if there is a wound and they are receiving treatment. We've identified there is a problem that skin evaluations are not being completed. On 05/11/2022 9:30 a.m., RN #1 was interviewed regarding the wound evaluations. RN #1 provided a binder which documented the facility's weekly wound rounds and supporting documentation. RN #1 stated the plans were once the new medical records staff was hired then the wound round information would be uploaded into the residents' electronic records. A review of the wound binder documented Resident #11's most recent wound evaluation was completed on 05/05/2022. The above findings were discussed with the administrator and DON during a meeting on 05/11/2022 at 5:30 p.m. 4b. On 05/11/2022 at 9:51 a.m., RN #1 was observed performing a dressing change Resident #11's sacral wound. RN #1 was observed carrying the dressing change supplies in her hands into Resident #11's room. RN #1 placed some of dressing change supplies on the sheet near the head and feet of Resident #11 who was laying in the bed. RN #1 then washed her hands and put on new gloves and removed the packed lodofoam from the sacral wound and disposed of the lodofoam in the trash can. RN #1 stated, I don't see the actual dressing. RN #1 wiped the sacral wound with a wipe. While wearing the gloves, RN #1 then opened the drawer to the bedside table and removed a bottle of skin prep and applied the skin prep to the sacral wound. RN #1 then used hand sanitizer and put on new gloves. RN #1 packed the sacral wound with the lodofoam using a sterile applicator and placed the foam dressing over the sacral wound. RN #1 then removed the right hand glove and dated the dressing with her right hand pressed against the outside of the dressing. RN #1 then put a new glove back on her right hand and placed the foam and skin prep inside the bedside table and assisted Resident #11 with dressing and straightening her clothes. RN #1 did not set up a clean sterile prep area prior to the sacral wound dressing change observation. On 05/11/2022 at 5:18 p.m., RN #1 was interviewed regarding observed dressing change. RN #1 stated, I realized immediately I should have set up a clean sterile prep area by cleaning and draping the top of the bedside table instead of placing the supplies on the bed. The above findings were discussed with the administrator & DON during a meeting on 05/11/2022 at 5:30 p.m. 5. Resident #20 was admitted to the facility with diagnoses that included anxiety disorder, hyperlipidemia, history of breast cancer, gait and mobility abnormalities, back pain, dysphasia, type 2 diabetes, obesity, bipolar disorder, hypertension, let pain and GERD. The most recent minimum data set (MDS) dated [DATE] was a 5-day and assessed Resident #20 as cognitively intact with a score of 15 out of 15. Resident #20 was interviewed on 05/10/2022 during the initial tour. Resident #20 was asked about the quality of care and quality of life since being admitted to the facility. Resident #20 stated, I'm almost totally dependent on staff especially with transfers, bed mobility and toileting. They use the hoyer lift to transfer me because of my leg issues and sometimes it takes two people. My skin is fragile and so far I haven't had any bed sores. But I get worried that they don't have enough staff to take care of us all. Resident #20 was asked if staff routinely checked her skin for pressure areas or other skin related issues. Resident #20 stated, No not all the time. I had an allergic reaction to some shampoo last week and saw the doctor because my face was red. We talked about having them transfer me to my lift chair daily so I can change positions and get out bed more. She said that changing positions would help prevent skin problems. Resident #20's clinical record was reviewed on 05/10/2022. Observed on the order summary report was the following: out of bed to chair daily one time a day. Order/Start Date: 05/05/2022. Resident #20's care plans documented a focus area for potential for impairment to skin integrity related to fragile skin. A pressure ulcer risk assessment completed on 2/21/2022 documented Resident #20 was at high risk for developing pressure ulcers. The assessment documented Resident #20 as being confined to the bed and having very limited mobility. A review of the skin assessments documented the last skin evaluation was completed on 03/09/2022. On 05/11/2022 at 8:45 a.m., the licensed practical nurse (LPN) #2 who routinely provided care for Resident #20 was asked about the missing skin assessments. LPN #2 reviewed Resident #20's clinical record and stated, I know she will refuse treatment sometimes including skin assessments. Looking at the record the last one was completed in March. They are supposed to be done weekly. LPN #2 was advised the clinical record did not document Resident #20 refusing skin assessments. The above findings were reviewed with the administrator and DON during a meeting on 05/11/2022 at 5:30 p.m. 6. Resident #62 was admitted to the facility with diagnoses that included atrial fibrillation, congestive heart failure, bipolar disorder, above knee amputation, history of fails, hyperkalemia, type 2 diabetes, hypothyroidism, and heart failure. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #62 as moderately cognitively impaired with a score of 10 out of 15. Resident #62's electronic health record (EHR) was reviewed on 05/10/2022. Observed on the order summary report was the following: turn and reposition before an after meals and every two hours from 8 p.m. til breakfast every shift. Order/Start Date: 01/07/2022. Resident #62's care plans documented a focus area potential/actual impairment to skin integrity. A pressure ulcer risk assessment completed on 01/07/2022 documented Resident #62 was at moderate risk for developing pressure ulcers. The assessment documented Resident #62 as being confined to bed, having very limited mobility and potential problems skin impairment related to friction and shear while in bed. A review of the skin assessments documented the last skin evaluation was completed on 3/4/2022. On 05/11/2022 at 9:15 a.m., the DON was interviewed about the missing skin evaluations. The DON stated, We've identified some issues with skin assessments not getting done. They are supposed to be done weekly. I know (Resident #62) refuses care and medications. He probably just refused them. The DON was advised a review of the record did not document Resident #62 refusing skin assessments. The above findings were discussed with the administrator and DON during a meeting on 05/11/2022 at 5:30 p.m. 7. Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, dementia without behavioral disturbance, weakness, hypertension, stage 3 kidney disease, adult failure to thrive, and encounter for palliative care. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #51 as severely cognitively impaired with a score of 0 out 15. Under Section G - Functional Status, the MDS assessed Resident #51 as requiring extensive assistance with one person physical assistance for dressing, personal hygiene, bed mobility, and toileting; total dependent for bathing; and supervision for eating. On 05/10/2022 during the initial tour Resident #51 was observed lying in bed asleep. A bruise was observed on Resident #51's right eye. Resident #51's clinical record was reviewed and documented the following progress note: 5/9/2022 13:18 (1:18 p.m.) NURSES NOTE Note Text: nurse on previous shift reported resident having a bruise on the side of her right eye. this nurse went in to check on resident at shift change, there is a bruise around right eye and resident is unsure how it happened. A review Resident #51's clinical record documented the last skin evaluation was completed on 04/27/2022. A review of the care plans included a focus area with goals and interventions for pressure injuries and/alteration in skin integrity. On 05/11/2022 at 11:30 a.m., the DON stated a full skin assessment had been completed a few minutes earlier. The DON was advised a review of the clinical record documented the last skin evaluation was on 04/27/2022. The DON stated, I told you earlier that we identified an issue with skin assessments not getting done. The above finding was discussed with the administrator and DON during a meeting on 05/11/2022 at 5:30 p.m. Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to assess and implement interventions for the treatment of pressure ulcers for eight of 22 residents, Resident #73, #80, #238, #20, #62, #51, #11, and #35. Resident #73 was admitted to the facility with a Stage IV pressure ulcer to the sacrum. There was no skin assessment, measurement, or intervention for treatment of the pressure ulcer at the time of admission. Resident #80, #238, #20, #62, and #51, all identified as being at risk for the development of pressure ulcer/skin injury, did not have weekly skin assessments completed. Resident #11 did not have weekly skin assessments completed and the facility staff failed to follow infection control practices during a dressing change. Resident #35 did not have accurate and timely skin assessments for pressure ulcer prevention and the facility failed to adequately monitor and provide ongoing assessments of a facility acquired deep tissue injury. Findings were: 1. Resident #73's was admitted to the facility with the following diagnoses including but not limited to: osteoarthritis, hypertension, morbid obesity, acute respiratory failure, diabetes mellitus, and Stage IV Sacral pressure ulcer. Due to her recent admission there was no MDS (minimum data set) assessment. According to her admission assessment dated [DATE], she was oriented to person, place, time, and situation. An admission nursing assessment dated [DATE] was reviewed. Under the Skin Integrity section, the following was documented: Color -Normal; Temperature-Warm .dry; Turgor-Normal; Integrity-Skin. Resident has-Pressure Ulcer/s. Description of the pressure ulcer was documented as: Site: Sacrum; Type: Pressure; Length/Width/Depth: NO ENTRY; Stage: IV; Details/Comments: NONE entered. The admission assessment also contained a base line care plan under skin integrity for Pressure Ulcer. Interventions included: Administer treatments as ordered, monitor dressing to ensure it is intact and adhering . The physician orders were reviewed. There were no orders for treatment of a pressure ulcer. On 05/11/2022 at approximately 8:15 a.m., RN (Registered Nurse) #2 was asked if dressing changes were scheduled for Resident #73. She stated, I stayed over yesterday and got that done so we can get it on the right days .she has a wound vac .it won't be changed again until Thursday unless something happens and it comes off. She was asked if the wound had been measured. She stated, No, I didn't do that. The clinical record was reviewed again at approximately 9:00 a.m., and there were no orders observed for the pressure ulcer. At approximately 3:00 p.m., the clinical record was reviewed again and an order for wound care was observed. The order dated 05/11/2022 with a start date of 05/12/2022 was for the following: Wound Vac to sacrum stage 4 ulcer change Tuesday Thursday and Saturdays. [NAME] foam to be used in tunneling and over bone. Settings 150 one time a day every Tue, Thu, Sat for Stage 4 ulcer. The above information was discussed with the DON (director of nursing) and the administrator on 05/11/2022 at approximately 53:0 p.m. The DON stated that orders for the care of a pressure ulcer should be obtained at the time of admission. They were asked when a pressure wound should be measured and assessed. The DON stated, Within 24 hours of admission .all skin assessments should be done within 24 hours of admission. On 05/12/2022 at approximately 8:30 a.m., the administrator stated, There was no order for wound care written at the time of admission. She did not have her wound vac on when she came from the hospital we should have gotten orders when she got here but that didn't happen .we also should have done a complete skin assessment including measurement of the pressure ulcer. On 05/12/2022 at approximately 2:15 p.m., RN #2 was interviewed regarding the dressing change that she did on the afternoon of 05/10/2022 and what orders she had followed. She stated, Nobody got any orders when she got her .the wound vac came with her from the hospital but nobody got orders for it or put it on her .the nurse practitioner came in on Tuesday and said we needed to get it on her and she gave me orders then .I put the wound vac on that afternoon I got busy and forgot to put the orders in until the next day (05/11/2022). She was asked if she had done a wound/skin assessment at that time. She stated, No, I did not .I stayed over to get the wound vac on her. I didn't measure the wound, it was late and we were busy .like I said I even forgot to put the orders in until I got back here for my next shift . She was asked if anything had been over the wound prior to the application of the wound vac. She stated, The hospital sent her here with a dressing on it .I had to take that off to put the wound vac on. LPN (licensed practical nurse) #1 was sitting at the nurse's station during the interview with RN #2. She stated, You have to understand .we are providing direct focus care, that's all we have time for .we make sure the residents get their medications, get fed, and we try to keep them safe .it is like being in a war zone, we have to triage the patients for their main needs .forgive me for saying it, but screw the documentation .we don't have time to do skin assessments .it is the basics. RN #2 stated, That's right. The facility policy, Pressure Injury Prevention and Management, contained the following: Pressure ulcer/injury risk assessment will be conducted on admission/readmission to the nursing facility .Documentation of the evaluations/assessments of the pressure ulcer/injury will (be) maintained in the resident's medical record. Documentation may include: .location, date acquired .description of the ulcer/injury to include stage, measurements (length, width, depth), presence/absence of any tunneling or undermining, type of tissue (epithelial, granulation, slough, necrosis, etc.), presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain .treatment and interventions to promote healing. No further information was obtained prior to the exit conference on 05/19/2022.2. Resident # 80 was admitted to the facility with diagnoses to include, but not limited to: stroke, peripheral artery disease, high blood pressure, and dysphagia following a stroke. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had Resident # 80 coded with moderate impairment in cognition with a score of 04 out of 15. The clinical record was reviewed 5/11/22 beginning at 8:00 a.m. The current care plan identified Resident # 80 as being at risk for pressure injury/alteration in skin integrity. Interventions included Monitor/document/report any changes in skin status. A Braden Scale For Predicting Pressure Sore Risk dated 4/27/22 assessed Resident # 80 as High Risk for pressure sore development. Resident # 80 was assessed as Very Limited for sensory perception, Very Moist for the skin being exposed to moisture with linens needing changed once per shift, Very Limited in mobility, Probably Inadequate nutrition, and as Potential Problem for friction and shear, in which skin slides to some extent against sheets, chair, or other devices. A skin assessment dated [DATE] noted Pt. (patient) w (with) /bruising to BUE (bilateral upper extremities) due to IV's. Scattered scabs noted to BUE also, but not open at this time. The physician orders were reviewed, and there were no orders for skin assessments. There were no other skin assessments in the clinical record. The administrator, DON, and DON from a sister facility were informed of the above findings 5/12/22 at approximately 8:15 a.m. No further information was provided prior to the exit conference. 3. Resident # 238 was admitted to the facility with diagnoses to include, but were not limited to: Non-alcoholic steatohepatitis (NASH), asthma, diabetes, and high blood pressure. There was no MDS (minimum data set) information as the resident was newly admitted less than fourteen days. On initial interview 5/10/22 at approximately 1:00 p.m. the resident conversed appropriately and was cognitive. The clinical record was reviewed 5/10/22 beginning at 11:00 a.m. The baseline care plan included the resident was identified as being at risk for pressure injuries. Interventions included weekly skin assessments. The assessment section of the clinical record did not include any skin assessments for Resident # 238. On 5/11/22 at 11:15 a.m. the DON (director of nursing) was asked about skin assessments and orders for skin assessments. The DON stated, All admissions should have skin assessments. Those are put in by the admitting nurse. They are 'standing orders' that are in a batch order file using a drop down box in the order section and they are to pick those orders. The physician does not need to order that. When skin is assessed on admission, the nurse is responsible for making sure those orders are selected. Every resident should get weekly skin assessments. On 5/12/22 at 7:50 a.m. RN (registered nurse) # 2 was interviewed about skin assessments. She stated No, skin assessments aren't done. There's not enough staff, I'm the only nurse and I'm giving medications, doing treatments, and by the time I finish passing medications, it's time to start again, if I don't get an admission. We don't have a unit secretary anymore. The new company has said nursing homes don't have unit secretaries, but this floor is the skilled unit. I am just one nurse .so, in addition to admissions, discharges, medications, treatments, etc., then it's up to me to make sure resident's have appointments scheduled and have transportation. When we had a unit secretary, then some of the ancillary work .putting charts together, dealing with appointments .was done by that person and at least we could get our 'nursing work' done. The administrator, DON (director of nursing), and DON from a sister facility were informed of the above findings 5/12/22 at approximately 8:15 a.m. A review of the clinical record was done 5/18/22 and there were no skin assessments for Resident # 238, fifteen days since admission. No further information was provided prior to the exit conference 5/18/22.8. Resident #35 was admitted to the facility with diagnoses that included cerebral infarction with hemiplegia/hemaparesis, hyperlipidemia, hypertension, constipation, osteoporosis, anemia, seizures and status post gastrostomy. The minimum data set (MDS) dated [DATE] assessed Resident #35 with moderately impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility, toileting and hygiene. Resident #35's clinical record documented a nursing note dated 1/27/22 stating, .Resident noted to have a DTI (deep tissue injury) Right heel .Wound photo taken. See for measurements. Wound is intact .denies pain. Both heels floated .Recommend Skin Prep and Foam patch . Resident #35's clinical record included no photograph, measurements or any description of the right heel DTI when identified on 1/27/22. Physician ordered treatment of skin prep with a foam patch was started on 1/28/22. There were no assessments of the right heel DTI providing the wound size, appearance, pain presence or color. There was no documentation of the DTI status from 1/27/22 until five weeks later on 3/3/22. Skin evaluations completed after identification of the right heel DTI had conflicting assessments of the resident's skin. The skin evaluation form dated 2/4/22 documented the resident had no current skin issues and made no mention of the right heel DTI identified on 1/27/22. A skin evaluation form dated 2/8/22 documented the resident had no current skin issues and stated, Skin is dry and intact. Discoloration noted to Bilateral feet and Right heel. A skin assessment dated [DATE] documented the resident had other open lesions on foot and listed the location as heels with no pain and warm tissue. It was unclear from this assessment if one or both heels were involved and if this open lesion was the DTI previously assessed on 1/27/22. There were no further skin assessments, body audits or wound assessments for Resident #35 until three weeks later on 3/3/22. A skin and wound evaluation form dated 3/3/22 documented the resident had an in-house acquired deep tissue injury measuring 4.6 cm x 2.0 cm (length by width in centimeters) with depth not applicable. This assessment listed the wound as improved with no signs of infection, no odor, no drainage and with dry/flaky skin surrounding the injury. A nursing note dated 3/11/22 documented, Patient DTI to Right Heel is resolved. The area is pink, new, healthy tissue. Periwound skin is intact .Heels will continue to be floated as patient allows to prevent breakdown. Resident #35 had no routine skin assessments and/or body audits for the next four weeks following the healed DTI. The next routine skin assessment was 4/18/22 and listed the resident had no skin impairments. As of 5/10/22, Resident #35 had no further skin assessments for pressure ulcer prevention since the 4/18/22 audit. The clinical record reviewed since November 2021 include no pressure ulcer risk assessment. On 5/11/22 at 9:47 a.m., the licensed practical nurse (LPN #2) caring for Resident #35 was interviewed about the resident's skin status and ongoing assessments. LPN #2 stated the resident currently had no wounds and she was not sure why the routine skin assessments were not performed. LPN #2 stated she had worked in the facility for a few weeks and thought the skin assessments were supposed to be done weekly. On 5/11/22 at 11:02 a.m., with the resident's permission and accompanied by certified nurses' aide (CNA) #1, a body audit was conducted with Resident #35. The resident had no open wounds or areas of skin impairment. Bunny boots and a heel cushion were in place as ordered. The resident's heels had dry, flaky skin but no pressure injuries were observed. On 5/11/22 at 3:58 p.m., the director of nursing (DON) was interviewed about the lack of routine skin assessments and no monitoring of the DTI. The DON stated weekly skin assessments had been identified as an issue in the facility due to staffing, use of agency staff and a combination of lots of things. The DON stated skin assessments were supposed to be completed on all residents weekly. The DON stated floor nurses performed wound care/treatments and wound monitoring was supposed to be documented by the wound nurse practitioner. On 5/11/22 at 5:18 p.m., the assistant director of nursing (ADON) was interviewed about any wound records and/or assessments of Resident #35's DTI. The ADON stated when she started performing wound rounds with the nurse practitioner, Resident #35's DTI was healed. The ADON stated she did not know why the wound was not monitored. Resident #35's plan of care (revised 4/27/22) listed the resident had impaired mobility due to hemiplegia and required two-person physical assistance for bed mobility and was totally dependent on staff for toileting and hygiene. The care plan listed the resident was at risk for skin impairment due to prior DTI, incontinence and immobility. Interventions to maintain skin integrity included bunny boots to feet, good nutrition/hydration, identification/documentation/elimination of potential causative factors and keeping skin clean/dry. The facility's policy titled Pressure Injury Prevention and Management (undated) documented, .pressure ulcer/injury risk assessments will be conducted quarterly, with significant changes in resident condition, and as needed .assessments will be conducted by a licensed/registered nurse and will be documented in the resident's medical record .Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record .Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change .Documentation of the evaluations/assessment of the pressure ulcer/injury will (be) maintained in the resident's medical record .Documentation may include .Location of ulcer/injury .Date that the ulcer/injury was acquired .Description of the ulcer/injury to include stage, measurements [length, width, depth], presence/absence of any tunneling .type of tissue .type of drainage, surrounding tissue description, and presence/absence of pain . The facility's policy titled Pressure Injury Prevention and Management (undated) defined a deep tissue injury as, Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss . This finding was reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, staff interview, and clinical record review, the facility staff failed to ensure supervision and interventions to prevent accidents for two of 22 residents in the survey sample, Resident #47, and #9. The facility failed to provide appropriate footwear and supervision to prevent falls as per the comprehensive care plan for Resident #47. Resident #9, with a non-functioning wander prevention device, eloped from the facility without staff knowledge and/or supervision. Findings include: 1. Resident #47 was admitted to the facility with the following diagnoses, including but not limited to: Alzheimer's disease, diabetes mellitus, hypertension, history of falling and conduct disorder. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/18/2022 assessed Resident #47 as severely impaired with a cognitive summary score of 00. On 05/10/2022 beginning at approximately 11:15 a.m., Resident #47 was observed walking in the hallway on Unit 2. The unit had two long hallways connected on each end by a shorter hallway creating a loop around the unit. Resident #47 walked the loop unassisted and unaccompanied, multiple times. She was wearing a light pink pair of fuzzy socks without shoes. At approximately 11:30 a.m., Resident #47 was observed walking down the hallway with the nurse practitioner (NP). The NP assisted Resident #47 to her room and was observed putting her shoes on her. She stated, (Name of Resident #47) let me help you with your shoes, I don't want you to fall. At approximately 12:05 p.m., Resident #47 came to the medication cart where RN (registered nurse) #2 was standing. Resident #47 was tearful, she said I don't know and put her head down on the medication cart. RN #2 offered her a snack, Resident #47 repeated, I don't know. OS (Other staff) #2 came down the hall and redirected Resident #47 by asking her to go and help with a project. The clinical record was reviewed on 05/10/2022 at approximately 12:30 p.m. The comprehensive care plan included the following: Focus area: Behaviors: (Name) has potential of yelling/cursing at others when she becomes upset, has been successful in removing own wanderguard. Interventions included: Assess potential cause(s) of deterioration ., check wanderguard for placement. redirect as needed . Focus area: The resident has had an actual fall unwitnessed fall without injury 2/26/22, unwitnessed fall with minor injury on 3/17/2022, Fall 3/23/22, Fall X 2 3/30/2022, Fall 4/1/22, fall 4/29/22 in hallway- Left arm bruise, Fall 5/1/22 stumbled in hallway. Interventions included: 4/1/22 hematoma hip sent to ED/Hospital. Plan is decrease in Risperadol, 4/29/22 Monitor resident while walking in hallway, 5/1/22 Continue to monitor Resident in hallway, Ensure patient is wearing appropriate non-skid footwear when ambulating, fall 1/3/2022 house shoes removed from room. fall 1/6/22-continue same plan of care, Hipsters as patient allows 3/30/2022, monitor resident when out in hallway and encourage to take rest periods during times of wandering . The progress note section documented Resident #47 sustained falls on the dates as listed in the comprehensive care plan. Resident #47 was also documented as entering other resident rooms. 5/9/2022 23:37 (11:37 p.m.) Behavior Note . Pt went into room (number) w (with)/ clothes requesting pt change her clothes resulting in patient (room number) falling. On 05/11/2022, at approximately 8:30 a.m., Resident #188, who was alert and oriented, was interviewed. She stated, There is a patient (Resident #47) here who comes in my room .she yells at herself in the mirror and tries to get into my bathroom .I know she can't help it, but it bothers me .I can't get up or get away from her if she comes toward me, I feel very vulnerable. On 05/11/2022 at approximately 9:45 a.m., RN #2 was interviewed regarding Resident #47. Observations of Resident #47 wandering in the hallway without proper footwear, concerns voiced by Resident #188, and the documentation of multiple falls, the most recent with a resulting hematoma to her hip were discussed. RN #2 was asked how the staff provided supervision for Resident #47. She stated, She wanders constantly .supervising her is a 'task'. She is in constant motion. RN #2 was asked why Resident #47 was on the skilled unit. She stated, She likes to be outside. We can't put her on 3rd floor because of the balcony and she can't be on first floor because she is an elopement risk, so she's down here. The social worker (OS #7) was interviewed at approximately 10:00 a.m. She was asked if she was involved with Resident #47. She stated, We are trying to place her .she needs a locked unit, but no one will take her. The DON (director of nursing) was interviewed on 05/11/2022 at approximately 12:23 p.m. Concerns were voiced regarding Resident #47's safety on the unit. She stated, I know, she should be one to one. She was asked why if she felt Resident #47 should have one to one care was it not being provided. She stated, We do not have the staff for that .we are trying to get her placed somewhere else .she should be on a locked unit. On 05/11/2022 at approximately 3:00 p.m., Resident #47 was observed up wandering in the hallway. She stopped at the nurse's station and put her head down, she stated, Oh my God. Resident #47 was wearing a pair of green legging type pants, no hipsters were observed. She was asked if she was wearing any pads/cushions on her hips. The unit secretary stated, She's not wearing them .she won't let them put them on her. An end of the day meeting was held with the DON and the administrator on 05/11/2022 at approximately 5:30 p.m. The above information was discussed. Concerns were voiced regarding Resident #47's wandering, inappropriate footwear, not wearing hipsters, multiple falls, behaviors of yelling and going in and out of other resident rooms making them feel vulnerable and actually causing one resident to fall resulting in a trip to the emergency room. The administrator stated, This is not a safe environment for her, she is not getting the best care needed, she needs a locked unit. The administrator was asked to clarify what was meant by her statement. She stated, I mean she is not getting the best care for her, I believe she is safe here with the proper footwear .the best thing for her would be a locked unit and we are working on that. The DON was asked to clarify her statement earlier that the resident needed one to one. She stated, She is lonely, she likes attention. On 05/12/2022 at approximately 8:30 a.m., the administrator stated, We added her (Resident #47) hipsters to the physician orders, we need an order for those .so now it is on the orders and added to the TAR (treatment administration record) for the nurses to track if they are on or off or refused we also placed her on one to one today. The administrator was asked why Resident #47 was placed on one to one and where did the staff person come from since the DON had stated there was not enough staff for that. She stated, Your concerns are our concerns .based on our conversation yesterday we feel that it is best to put her on one to one during waking hours. We'll use auxiliary staff to entertain her, if we don't have auxiliary staff the DON, the ADON, or myself will sit with her. We will get it on the care plan and in the progress notes, we just haven't gotten to that yet, we literally just started it at 7:00 this morning .we are also actively seeking placement for her. On 05/16/2022 at 10:55 a.m., Resident #47 was observed lying on her bed asleep. There was no one in the room with her. There were no staff members on that side of the unit. CNA (certified nursing assistant) #4 was outside of a resident's room on the other side of unit. She was asked if she knew who was sitting with Resident #47. She stated, I think it is (Name of CNA #5). She was asked if she knew where CNA #5 was. She stated, In the resident's room I guess. She was told that no one was in the room with Resident #47. She stated, I don't know where she is then, but I've been in another room, hang on. She went down the hallway and spoke to another CNA. She came back and said, We don't know where she is. She was asked if CNA #5 had reported off to anyone. She stated, Not that I know of .there are four of us up here today but I think that includes her. At approximately 11:00 a.m. Resident #47 woke up and came out into the hallway. CNA #4 and LPN (licensed practical nurse) #2 came down the hallway at that time. LPN #2 stated, I don't know where (Name of CNA #5) is .she may have gone down to get lunch. I didn't know she was gone. The business office manager came to Resident #47's room and stated, She only needs a sitter during waking hours. She was asked to define waking hours since it was 11:00 a.m. and most residents are awake during that time, and how do the staff know when she is awake if no one is in the room. She did not answer. Resident #47 walked out into the hallway and the business office manager took her outside to the balcony area. At 11:10 a.m., CNA #5 returned to the unit. She stated she had gone down to the picnic to get her lunch. She was asked if she had reported off to anyone on the unit that she was leaving the floor and leaving Resident #47 unattended. She stated, No, I didn't, my bad, but she was asleep when I left. She was asked what she had been instructed/assigned to do with Resident #47 and what she had been told in report. She stated, I didn't get a report .I guess just sit with her, keep an eye on her I thought I only needed to be in here if she's awake .I've been out helping the girls today if she was sleeping. She was asked what she meant by helping the girls. She stated, Passing trays. She was asked what would happen if she got tied up in a room while passing trays and Resident #47 woke up. She stated, I don't know. The administrator was informed at approximately 11:25 a.m., that Resident #47's one to one assigned staff had been off the floor without notifying any staff that she was gone, and the question regarding what waking hours meant. She stated, I need to clarify the care plan. On 5/18/22 at 3:15 p.m. an observation of Unit 3 was conducted. Resident #47 was observed sitting on her bed, unattended. CNA #6 was several doors down, obtaining vital signs for residents, CNA #7 was standing with her. CNA #6 was asked about her assignment for the shift, and she responded I really don't know yet; we (She and CNA #7) got up here a little before 3:00 (p.m.), but there was no one here so I just started doing vitals to get something started . CNA #7 echoed that statement. The CNA's were then asked who was assigned to (name of Resident #47), and both CNA's asked Who is that? They were advised of the one to one supervision for the resident, and they stated they did not know anything about the resident, or that particular need for her. At that time, Resident #47 was observed out of her room, and wandering the hall. Resident #47 was identified for staff, and CNA #6 stated Well, I can do that; I have no idea what I'm supposed to do with her or for her, but I can do it . On 5/18/22 at 3:30 p.m., LPN #7, was asked about staff assignments for CNA's, and who was assigned to Resident #47. LPN #7 stated I had to go down to the first floor to see about some medications. I haven't made assignments for the with one to one Resident (#47) yet . LPN #7 was asked if it had been decided what was meant by one to one during waking hours on the careplan. The DON, who was at the medication cart a few feet away, stated Someone should be with her 24/7. No further information was obtained prior to the exit conference on 05/19/2022. 2. Resident #9 was admitted to the facility with diagnoses that included vascular dementia with behavioral disturbance, vitamin D deficiency, major depressive disorder, hypothyroidism, atherosclerotic heart disease, benign prostatic hyperplasia, hypertension and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #9 with severely impaired cognitive skills. On 5/10/22 at 2:18 p.m., Resident #9's family member was interviewed about quality of care in the facility. The family member stated the resident was found several days ago by hospital staff wandering in the adjacent hospital without supervision. The family member stated she heard this from a person that did not work for the facility and thought the resident's Wanderguard device was not working. On 5/11/22 at 11:06 a.m., the certified nurses' aide (CNA) #1 caring for Resident #9 was interviewed. CNA #1 stated the resident wandered about the unit frequently and wore a Wanderguard device on his ankle. CNA #1 stated it was communicated during shift report that Resident #9 was found on the hospital side of the building and that the Wanderguard device was not working. CNA #1 stated she was not working when the incident happened. On 5/11/22 at 11:13 a.m., the licensed practical nurse (LPN) #2 caring for Resident #9 was interviewed about any recent elopements. LPN #2 stated it was communicated during shift report that Resident #9 was found by hospital staff and brought back to the facility. LPN #2 stated this happened in the last couple of weeks but she did not know the date of the incident. LPN #2 stated the resident's Wanderguard device was not working at the time of the incident. On 5/11/22 at 11:33 a.m., the director of nursing (DON) was interviewed about Resident #9's elopement. The DON stated she heard about the incident in the stand-up meeting on Monday (5/9/22). The DON stated the incident was not reported to the administrator, physician or family. The DON stated she was told the resident went through the door onto the medical-surgical unit of the connecting hospital. The DON stated the hospital staff returned the resident to the unit but she was not sure what time the incident occurred. The DON stated, His (Resident #9's) Wanderguard battery was dead. On 5/11/22 at 3:00 p.m., the administrator was interviewed about an elopement incident with Resident #9. The administrator stated the resident's daughter called her yesterday (5/10/22) and reported she heard the resident was found in the adjacent hospital. The administrator stated she had not been notified by facility staff about the incident. The administrator stated the incident happened on 5/8/22 with LPN #3 working. The administrator stated she had not yet talked with LPN #3 about the details of the incident. On 5/11/22 at 3:53 p.m., the DON was interviewed about a prior elopement or wandering risk assessment for Resident #9. The DON stated she did not find an elopement and/or wandering risk assessment for Resident #9. On 5/12/22 at 9:43 a.m., LPN #3 that cared for Resident #9 on 5/8/22 was interviewed. LPN #3 stated she was administering medications during the evening shift on 5/8/22 when a therapist and another hospital employee brought Resident #9 back to the unit. LPN#3 stated the hospital staff found the resident wandering on the medical-surgical unit of the hospital which is on the connecting floor to the resident's living unit. LPN #3 stated the incident occurred between 8:00 p.m. and 10:00 p.m. LPN #3 stated she had last seen the resident on his bed around 7:15 p.m. or 7:30 p.m. when she gave him medications. LPN #3 stated, I did not know he (Resident #9) was off the floor. LPN #3 stated when the resident was returned to the unit, she checked the Wanderguard device and found that it was not working. LPN #3 stated she could not locate a replacement battery pack for the device so the resident went the remainder of the night without a functioning Wanderguard. LPN #3 stated she worked the rest of the night and reported the incident and the non-functioning Wanderguard to the oncoming day shift (5/9/22 at 7:00 a.m.). LPN #3 stated Resident #9 wanders a little and has cognitive impairment. LPN #3 stated the Wanderguard device, when working, locked the exit doors and alarmed to prevent unauthorized and unsupervised exits. Resident #9's clinical record documented a physician's order dated 12/10/21 for a wander prevention device due to risk of elopement with instructions to check the device each shift to ensure function and replace if needed. Resident #9's clinical record for May 2022 made no mention of the 5/8/22 elopement incident and included no mention of a non-functioning wander prevention device. The resident's TAR (treatment administration record) for May had no check of the Wanderguard function on the evening and night shift on 5/8/22. There was no documented elopement/wandering risk assessment prior to the 5/8/22 incident. Resident #9's plan of care (revised 4/27/22) documented the resident was an elopement risk and wanderer. Interventions listed to maintain resident safety were, Assess for fall risk .Monitor for fatigue and weight loss .Provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, pictures and memory boxes .WANDER ALERT device. Check for placement . These findings were reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #62 was admitted to the facility with diagnoses that included atrial fibrillation, congestive heart failure, bipolar disorder, above knee amputation, history of fails, hyperkalemia, type 2 diabetes, hypothyroidism, and heart failure. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #62 as moderately cognitively impaired with a score of 10 out of 15. Resident #62's electronic health record (EHR) was reviewed on 05/10/2022. Observed on the order summary report were the following orders: Hiprex Tablet (Methenamine Hippurate) Give 1 gram by mouth two times a day for prophylactics and suppression of uti. Order Date: 03/31/2022. Start Date: 04/01/2022. Lactobacillus Capsule Give 1 capsule by mouth two times a day for frequent UTIs. Order/Start Date: 02/09/2022. Resident #62's EHR including the medication administration record (MAR) for the month of May 2022 documented Resident #62 missed the Hiprex morning doses on 5/7/2022, 5/8/2022, 5/9/2022, and 5/10/2022 and missed the Hiprex evening doses on 5/6/2022, 5/7/2022, 5/8/2022, 5/9/2022, and 5/10/2022. The progress notes documented the Hiprex was on order from the pharmacy. The EHR and MAR documented Resident #62 missed the Lactobacillus evening doses on 5/5/2022 and 5/6/2022. The progress notes documented the medication was unavailable because it was locked in the refrigerator and staff did not have a key to the refrigerator. On 05/11/2022 at 8:45 a.m., the licensed practical nurse (LPN) #2 who routinely provided care for Resident #62 was interviewed about the missed doses of medications. LPN #2 stated, We didn't have a key to the refrigerator where the Lactobacillus was stored that is why it was missed. I notified the DON and she provided us with a key on this floor. The Hiprex medication was on order from the pharmacy. We've had some problems with the pharmacy deliveries being late or having to send multiple order requests. I checked the med cart and that medication came in late last night or early this morning and I will administer it this morning. LPN #2 was asked if the nurse practitioner was notified about the missed doses. LPN #2 reviewed the EHR and stated, I was off a few days and looking at the record I don't believe she was notified. We probably should notify her of these problems. On 05/11/2022 at 9:15 a.m., the DON was interviewed about the missed doses. The DON stated a new lock was recently placed on the medication refrigerator and some of the staff were not provided a key for the new lock. The DON stated when LPN #2 advised her Resident #62 missed doses of the Lactobacillus due to it being locked in the refrigerator she immediately provided LPN #2 with a key. The DON was asked about the missed Hiprex doses. The DON stated the facility was having an issue with the pharmacy delivery because it was located in North Carolina. The DON was asked if staff had notified the NP about the missed doses. The DON stated, I'm not sure, we've identified some documentation problems. I honestly can't say if the nurses notified the NP or not and they just didn't document it. The DON was asked if the Hiprex was located in the Omnicell medication dispensing unit. The DON stated she would follow-up with the information. On 05/11/2022 at 5:30 p.m. the above findings were reviewed with the administrator and director of nursing. The DON stated the Hiprex medication was not available for dispensing in the Omnicell. The DON was asked about the expectation regarding notification of missed medication. The DON stated nursing should have notified the provider to see if an alternate medication could be prescribed and to notify herself and/or the administrator if there was a continuing problem with the pharmacy. On 05/11/2022 at 7:20 a.m., the administrator advised the NP was notified of the missed medication on 05/11/2022. Based on staff interview, facility document review and clinical record review, the facility failed to ensure medications were available for administration for two of twenty-two residents in the survey sample, Resident #33 and #62. Resident #33's prescribed medication Abilify was not available resulting in six missed doses. Resident #62's medications for urinary health were not available for administration. The findings include: 1. Resident #33 was admitted to the facility with diagnoses that included multiple sclerosis, hyperlipidemia, insomnia, major depressive disorder, morbid obesity, anxiety, polyneuropathy, hypertension, chronic pain syndrome, overactive bladder and obstructive sleep apnea. The minimum data set (MDS) dated [DATE] assessed Resident #33 as cognitively intact. Resident #33's clinical record documented a physician's order dated 12/15/21 for the medication aripiprazole (Abilify) 100 mg (milligrams) to be administered each day for treatment of major depressive disorder. Resident #33's medication administration record (MAR) for April 2022 documented the Abilify was not administered as ordered on 4/14/22, 4/15/22, 4/18/22, 4/23/22, 4/25/22 and 4/26/22. Nursing notes dated 4/14/22, 4/18/22, 4/23/22 and 4/26/22 documented the Abilify was not available on the medication cart and staff were waiting for delivery of the medicine from the pharmacy. On 5/11/22 at 4:03 p.m., the director of nursing (DON) was interviewed about Resident #33's missed medications. The DON stated there had been a lot of trouble with pharmacy. The DON stated the pharmacy was located out of state and orders/refills sent in after 4:00 p.m. were not processed until the next day. The DON stated she did not know why the Abilify was out of stock. On 5/12/22 at 9:15 a.m., the administrator stated Resident #33's Abilify was not here to give. The administrator stated Abilify was not available in the stocked emergency supply. This finding was reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m.

Based on medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. A medication pass and pour observation conducted on 05/10/2022 with 27 opportunities and 22 errors, yielded an medication error rate of 81.48 percent. Findings were: A medication pass and pour observation was conducted on 05/10/2022 beginning at approximately 11:00 a.m. with RN (registered nurse) #2. RN #2 was observed preparing medications for Resident #206. Two of the medication cards had administration instructions from the pharmacy, Prednisone 10 mg- Take with food or milk, and Metoprolol 25 mg- Give with or immediately following meal. Those two medications were given along with six other oral medications and eye drops. The oral medications were not given with food or milk. Also, ordered for Resident #206 was a 4% Lidocaine patch. The patch was not on the medication cart. RN #2 looked on the stock carts on the unit and was unable to locate the correct percentage. She left the floor and returned at approximately 11:55 a.m., with the correct dosage Lidocaine patch. The patch was applied to Resident #206's right shoulder at 12:05 p.m. RN #2 then prepared a total of nine medications for Resident #80. One of the medication cards had administration instructions from the pharmacy, Metoprolol 50 mg-take with or immediately after meals. Resident #80's medications were crushed, mixed with a spoonful of vanilla pudding and administered at approximately 12:20 p.m. After administering the medications RN #2 was asked what time the medications she had administered were scheduled. She stated, (Name of Resident #206) are due at 8:00 a.m. (Name of Resident #80) meds are scheduled for the 'AM'. She was asked what that meant. She stated, Anytime between 9:00 and 11:00 a.m. RN #2 was asked if all of the medications that had been observed during the medication pass were late. RN #2 was told that directions had been observed on the medication cards for some of the medications she had administered to be given with meals, food or milk. She stated, That's because they are due at breakfast time, hopefully lunch will be up here soon .I'm doing all I can do. The above information was discussed during an end of the day meeting on 05/11/2022 at approximately 5:30 p.m., with the DON (director of nursing) and the administrator. They were asked about the AM timing for Resident #80's medications. Neither the DON or the administrator knew what that meant. On 05/12/2022 at approximately 8:15 a.m., the DON were interviewed. The administrator stated, The AM time is a rollover from the (Name of previous facility owner) .it was used for resident's preferences for med times .the nurses are not supposed to be using that anymore .we have scheduled medication times. The administrator and DON were told that 19 medications were observed being administered to two different residents and all 19 were late, with additional errors regarding the pharmacy instructions to administer the medications with meals, food, and/or milk. The facility policy Medication Administration Schedule contained the following: Scheduled medications will be administered within one (1) hour of their prescribed time, unless otherwise specified .Time critical medications are designated by the prescribing practitioner and/or pharmacy and my include: medications that need to be administered before, with, or after meals . An additional facility policy, General Guidelines for Medication Administration, contained the following: At a minimum, the 5 rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration . No further information was obtained prior to the exit conference on 05/19/2022.

2. On 05/12/2022 at approximately 1:00 p.m., a medication cart on the first floor of the facility was observed with RN (registered nurse) #3. There were twenty-two (22) opened bottles of stock medication that were not dated with the date they were opened. RN #3 stated, I don't usually work down here .they are supposed to be dated when they are opened. She was asked how long they were used after opening or was the manufacturer's date used to know when to dispose of the medication. She stated, I'm not sure. Also observed on the medication cart was an opened vial of Lispro Insulin that was not dated. She stated, I don't see a date it needs to be thrown away. The medication cart on the second floor was observed with the ADON (assistant director of nursing) at approximately 1:15 p.m. There were five (5) bottles of stock medication on the cart that had been opened and not dated. The ADON was asked how long the medications were used after opening. She stated, Six months .they should be dated. There were also four opened bottles of insulin on the cart that were not dated and one opened bottle of Lispro insulin that was dated 03/27/2022, which had expired. The ADON stated, These all need to be thrown away. Also observed were two opened bottles of glucose monitoring strips that were not dated. The ADON stated, These should also be dated, they're good for 90 days after we open them but they need to be dated. The facility policy Storage of Medications contained the following information: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .the expiration date .will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly . No further information will be obtained prior to the exit conference on 05/19/2022. Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration; and also failed to date open vials of insulin and stock medications on the medication carts on three of three units. 1. Unit 3 medication carts included open vials of undated insulin and expired insulin. 2. Unit 1 and Unit 2 medication carts included a total of twenty-one house stock medications that were not dated, four vials of insulin open and not dated, and one bottle of expired insulin still in the medication cart and available for administration. Findings include: 1. On 5/10/22 beginning at 2:00 p.m. two medication carts were inspected with licensed practical nurse (LPN) # 2. One cart included three open vials of insulin that were not dated. The second medication cart included 1 vial of open insulin not dated, one vial of insulin dated 11/5/21, and one vial of insulin dated 3/19/22. LPN # 2 was asked about the insulins. LPN # 2 stated Yes, insulin should be dated when open as the 'shelf life' is shorter once the seal is broken. The insulin dated 11/5/21 belongs to a resident who has been discharged some time ago. The insulin dated 3/19/22 is a current resident, but his insulin order was changed. Those two vials should have been removed some time ago . On 5/10/22 at 2:45 p.m. the ADON (assistant director of nursing) was asked for a policy on storage and labeling of medications. The policy Vials and Ampules of Injectable Medications directed at # 6. Medication multi-dose vials may be used until the manufacturer's recommended expiration date if inspection reveals no problems during that time. USP (United States Pharmacopoeia) 797 guidelines recommend discarding multidose vials at 28 days after opening. The date opened and the triggered expiration date should be recorded on a label for such purpose affixed to the vial . On 5/11/22 the DON (director of nursing) was informed of the above findings. No further information was provided prior to the exit conference.

Based on observation, facility document review and staff interview, the facility staff failed to store resident food in a sanitary manner on three of three nursing units. Expired and/or undated food items were observed in the nourishment refrigerators on unit 1, unit 2 and unit 3. The findings include: On 5/11/22 at 11:19 a.m. the unit 3 nourishment refrigerator was inspected. Stored and available for use were five cartons of milk with use by date of 5/10/22. On 5/11/22 at 11:20 a.m., licensed practical nurse (LPN) #2 was interviewed about the expired milk. LPN #2 stated milk was usually consumed prior to the use by dates and the cartons needed to be discarded. On 5/11/22 at 11:57 a.m., the unit 2 nourishment refrigerator was inspected. Stored and available for use was an opened 16 ounce container of cottage cheese with use by date of 5/7/22. There was a Styrofoam container with a grilled ham/cheese sandwich with no date labeled for Resident #80. There were six cartons of milk with use by date of 5/10/22. On 5/11/22 at 12:00 p.m., LPN #1 was interviewed about the expired and/or undated food items. LPN #1 stated the dietary staff usually stocked the refrigerator with milk but nursing staff was supposed to monitor and discard personal resident food. On 5/11/22 at 12:05 p.m., the unit 3 nourishment refrigerator was inspected. There were three cartons of milk with use by date of 5/2/22, three cartons with use by date of 5/9/22 and four cartons with use by date of 5/10/22. On 5/11/22 at 12:07 p.m., LPN #5 was interviewed about the expired milk. LPN #5 stated kitchen employees were supposed to monitor and discard expired milk. The facility's policy titled Food Brought in by Visitors (undated) documented, .Facility provides storage for labeled/dated resident food in unit refrigerators .All items must be identified by resident name and date when placed in the refrigerator .Unopened refrigerated items must be dated with 'open' dates when opened. Food items will be discarded when unsafe for consumption .All food/beverage with passed manufacturer's expiration dates will be discarded . The facility's policy titled Nutrition Services - Cleaning and Sanitizing (undated) documented, .Nursing Unit refrigerators, for nourishment purposes, are the responsibility of Nutrition Services personnel .and are cleaned out as needed . This finding was reviewed with the administrator and director of nursing during a meeting on 5/11/22 at 5:30 p.m.

Based on facility document review and staff interview, the facility staff failed to employ a qualified dietitian. There had been no registered dietitian employed since 4/15/22 in the facility with a census of 73. The findings include: On 5/10/22 at 11:27 a.m., the dietary manager (other staff #1) was interviewed about qualified nutrition staff in the facility. The dietary manager stated there was currently no registered dietitian (RD) employed at the facility. The dietary manager stated the previous RD had been gone for approximately two to three weeks. Review of the facility's current personnel list (2022) included no identified RD for the facility. On 5/10/22 at 12:39 p.m., the administrator was interviewed about a RD for the facility. The administrator stated the previous RD quit and she was not sure if a new RD had been hired. On 5/11/22 at 8:22 a.m., the administrator stated the RD left about a week or two weeks ago and there was currently no RD for the facility. The administrator stated they were using the providers for nutritional guidance until a RD was hired. On 5/11/22 at 4:54 p.m., the administrator stated the previous RD's last day worked was 4/15/22 and the facility had been without a RD since then. This finding was reviewed with the administrator and director of nursing during a meeting on 5/12/22 at 8:15 a.m.

Based on staff interviews, family interview, clinical record review, and survey findings, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The census in the facility was 73. The facility staff failed to employ sufficient nursing staff which resulted in the identification of Immediate Jeopardy. The findings include: A survey was conducted at from 05/10/2022 through 05/19/2022. During the survey deficient practice was identified in the area of quality of care at F684, F686, F689 and pain management at F697. These identified areas of deficient practice were related to the facility not employing sufficient nursing staff. One of these areas resulted in identified harm for one resident in the survey sample for pain management. Additional deficient practice was identified for failure to follow physician orders, failure to provide services to prevent and/or treat pressure ulcers and failure to provide supervision for residents who were identified as wandering. During the survey interviews were completed with residents, families and staff concerning staffing. The interviews revealed the facility had lengthy call bell response between 30 minutes and 1 hour; physician ordered treatment and services were not being completed in a timely manner because of staffing shortages, the facility did not employ unit managers for oversight and assistance, medications were being administered 3 hours late, and the physician was not being notified of changes in conditions and/or missed medications. On 05/11/2022 at 11:30 a.m., the DON was interviewed regarding the concerns with staffing. The DON stated, We like to have one nurse per floor but because of staffing issues sometimes on third shift we may only have two nurses in the building and they will split the floor that doesn't have a nurse. It's not the ideal situation, but it's what we have to do. The DON was asked for clarification of her statement. The DON stated, We have three floors in this building so on nights we only have two nurses in the building, they will work their assigned floor and then split the floor that doesn't have an assigned nurse. Basically, they decide what time during the shift they check on that unit or as the CNAs notify them of concerns. The DON was asked if the facility had unit managers. The DON stated, No, we don't. The nursing staff is supposed to report to myself and/or the ADON. On 05/11/2022 at 12:43 p.m., the staffing coordinator (OS #2) was interviewed about staffing. OS #2 stated staffing was based off the facility's census. OS #2 stated the facility should be staffed as the following: 1st floor - LTC (long term care) for first and second shifts: 1 nurse and 3 CNAs, third shift: 1 nurse and 3 CNAs 2nd floor- rehab for first and second shifts: 1 nurse and 2 CNAs, third shift 1 nurse and 1 CNA 3rd floor - LTC for first and second shifts: 1 nurse and 3 CNAs, third shift 1 nurse and 2 CNAs OS #2 was asked about the process for call outs and/or to fill available staffing positions. OS #2 stated, I'm the first line of defense and they call me first. They also call the DON and night shift calls the DON. We do like for them to call the unit nurse, but that doesn't happen all the time so they at least call the DON. We use two different staffing agencies and I stay in contact with them for staffing needs. With the new ownership, I no longer have access to the electronic system to post available shifts so I have to make phone calls or send text/group messages. If there are slots that I can't fill, then I notify the administrator and DON. Human Resources has been posting positions online. We're offering 8 hour shifts Monday through Friday and 12 hour shifts on the weekends. Sometimes we have to split shifts and nursing staff will work four hours. We still have open slots. It's just been difficult to get staff. We're doing the best we can with the resources we have. On 05/12/2022 at 11:07 a.m., the survey team identified Immediate Jeopardy in the area of Nursing Services for the lack of sufficient nurse staffing. On 05/12/2022 at 6:26 p.m, during a meeting with the administrator and corporate consultant the administrator stated that the DON had left the facility for the day without notifying the administrator. The administrator was asked about the plan for nursing administration. The administrator stated she had a current nursing license and would provide oversight to the staff as well as the ADON, both who would work the floor and med carts as needed. The administrator stated she was not sure if the DON would return the next day. On 05/19/2022 at 9:21 a.m., the survey team abated the Immediate Jeopardy, which was subsequently lowered to a Level 3 - Isolated. No further information was provided prior to exit on 05/19/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #11 was admitted to the facility with diagnoses that included difficulty walking, stage 4 pressure ulcer to sacral region, vascular dementia without behaviors, type 2 diabetes, dysphasia, hypertension, hypothyroidism, hyperlipidemia, anemia, Vitamin D deficiency, and cerebral aneurysm. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #11 as severely cognitively impaired with a score of 5 out of 15. Resident #11's clincial record was reviewed on 05/10/22. Observed on the order summary report was the following: Cleanse sacral wound with wound cleanser, pack with lodofoam, wet with lidocaine/morphine, cover with foam dressing in the evening for wound care. Order/Start Date: 04/14/2022 On 05/11/2022 at 9:51 a.m., RN (registered nurse) #1 was observed performing a dressing change to Resident #11. RN #1 was observed carrying the dressing change supplies in her hands into Resident #11's room. RN #1 placed some of dressing change supplies on the sheet near the head and feet of Resident #11 who was laying in the bed. RN #1 then washed her hands and put on new gloves and removed the packed lodofoam from the sacral wound and disposed of the lodofoam. RN #1 stated, I don't see the actual dressing. RN #1 wiped the sacral wound with a wipe. While wearing the same gloves, RN #1 then opened the drawer to the bedside table and removed a bottle of skin prep and applied the skin prep to the sacral wound. RN #1 then used hand sanitizer and put on new gloves. RN #1 packed the sacral wound with the lodofoam using a sterile applicator and placed the foam dressing over the sacral wound. RN #1 then removed the right hand glove and dated the dressing with her right hand pressed against the outside of the dressing. RN #1 then put a new glove back on her right hand and placed the foam and skin prep inside the bedside table and helped Resident #11 with dressing and straightening her clothes. RN #1 did not set up a clean prep area prior to the sacral wound dressing change observation. On 05/11/2022 at 5:18 p.m., RN #1 was interviewed regarding observed dressing change. RN #1 stated, I realized immediately I should have set up a clean prep area by cleaning and draping the top of the bedside table instead of placing the supplies on the bed. A review of the facility's policy titled Clean Dressing documented the following: .Clean technique involves strategies used in resident care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies .Steps in Procedure: 1. Clean bedside table. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached . The above findings were discussed with the administrator & DON during a meeting on 05/11/2022 at 5:30 p.m. 2. Initial tour of the second floor of the facility was conducted at approximately 10:45 a.m. on 05/10/2022. RN (registered nurse) #2 was observed in Resident #73's room giving medications. She was wearing only a surgical mask. A sign beside the door read Contact Precautions. When RN #2 exited the room she was asked why Resident #73 was on contact precautions. She stated, She is a new admission, she's not vaccinated .we put them on precautions for ten days after they get here .she should be on droplet precautions not contact precautions. She went over to the doorway and removed the sign reading contact precautions and hung one up for droplet precautions. RN #2 was asked what PPE (personal protective equipment) was required for droplet precautions. She stated, N95, goggles, gown, the whole thing. She was asked if she had worn those items in Resident #73's room. She stated, No, I was not, I knew what I was supposed to do, my brain is having a hard time keeping up today. Resident #73's clinical record was reviewed at approximately 1:30 p.m., on 05/10/2022. Due to her recent admission there was no MDS (minimum data set) assessment. According to her admission assessment dated [DATE], she was oriented to person, place, time, and situation. The physician orders were reviewed. There were no orders for any type of infection control precautions. The base line care plan was reviewed. There were no interventions/problems listed regarding the need for isolation precautions. An end of the day meeting was held on 05/11/2022 with the DON (director of nursing) and the administrator. They were asked about the protocol for unvaccinated residents when they are admitted to the facility, and what PPE was required for droplet precautions. The DON stated that droplet precautions required the use of a surgical mask, gown, and gloves. She was asked if those precautions were the same when the droplet precautions were in place as a COVID precaution. She stated, she would look look into it. On 05/12/2022 at 8:15 a.m., the administrator stated that Resident #73 was tested for COVID prior to leaving the hospital and was negative. She was placed on droplet precautions due to her unvaccinated status. She stated, According to our policy, the staff should be wearing N95s not surgical masks. The facility policy Admitting/Re-Admitting Residents During COVID 19 Pandemic contained the following: Residents who have had close/prolonged contact .or residents who are not up-to-date: .Staff should wear an N95 or higher-level respirator, eye protection (i.e. goggles or a face shied that covers the front and sides of the face), gloves, and gown when caring for these residents. No further information was obtained prior to the exit conference on 05/19/2022. Based on observation, staff interview, and facility document review, the facility staff failed to implement a Legionella water management program in the facility; failed to follow infection control practices for proper PPE (personal protective equipment) when going in and out of a resident room for one of 22 residents, Resident # 73; and failed to follow infection control practices during a dressing change for one of 22 residents, Resident # 11. 1. The facility failed to implement a Legionella water management program in the facility. 2. Facility staff did not use proper PPE when entering Resident #73's room. There was also no order or care plan in place for droplet precautions for Resident #73. 3. Staff failed to follow infection control practices during a dressing change for Resident # 11. Findings include: 1. The facility's Legionella water management program was reviewed 5/12/22 beginning at 2:20 p.m. The central supply staff presented a test result for the hospital stating that he did not know who was in charge of Legionella for the facility, but that was all he could find. The administrator was asked who was in charge of the water management program, and she stated the engineering coordinator at the hospital would be able to help with that information. At the time of the survey, the facility did not have a maintenance worker/director. On 5/12/22 at 3:00 p.m., the engineer from the hospital was asked about the Legionella program, who was in charge for the facility, and where the information was located. The engineer, identified as Other Staff (OS) # 5, stated The facility is part of the hospital, so the water in the facility is considered as such also. OS # 5 was informed that the facility used to be part of the hospital, but was now owned by another entity. OS # 5 stated Well, when that company bought the facility, they contracted with us (staff at the hospital) to come over and perform any maintenance needed. We do run some water temperatures in resident rooms and in the shower, but the water lines from the hospital run into this facility . OS # 5 was then asked if he had conducted a facility Legionella environmental risk assessment to identify where the water entered the facility from the hospital, a water system schematic, and other data for Legionella. OS # 5 stated The new company never mentioned anything about doing Legionella . A policy entitled Water Management Program included the following: Policy: It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens (e.g. Pseudomonas, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems. Policy Explanation and Compliance Guidelines: 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the infection preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-bourne pathogens grow and spread .b. The water management team has access to water treatment professionals, environmental health specialists, and state/local heath officials. 2. The maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder. (sic). 3. A risk assessment will be conducted by the water management team annually .a. Premise plumbing .b. Clinical equipment .c. At risk population- this facility's entire population is at risk. High risk areas shall be identified through the risk assessment process. 4. Data to be used for completing the risk assessment may include, but are not limited to: a. Water system schematic/description b. Legionella environmental assessment .f. water temperature logs . 5. Based on the risk assessment, control points will be identified . OS # 5 was asked if that was the new company's logo on the policy, and he stated Yes. The policy was reviewed with him, and he was again asked if any item in the policy had been done. OS # 5 stated No. OS # 5 further stated the current company bought the facility in November 2021. The administrator was informed of the above findings 5/12/22 at approximately 4:45 p.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility document review, the facility staff failed to ensure an advance directive was signed by the authorized representative for one of 21 residents, Resident #78. Findings include: Resident #78 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: history of cancer, coronary artery disease, high blood pressure, pneumonia, and dementia. The most current MDS (minimum data set) was a quarterly review dated 11/21/19. This MDS assessed the resident with a cognitive 4, indicating the resident had severe impairment in daily decision making skills. On 02/05/20 during the clinical record review, Resident #78's advance directive was reviewed. The resident was listed as a DNR (Do Not Resuscitate) in the electronic clinical record. No other information could be located. On 02/05/20 at 1:30 PM, the ADON (assistant director of nursing) was asked for assistance in locating the actual DNR form and any advance directive information for this resident. On 02/05/20 at 2:00 PM, the ADON presented a DNR form and and copy of the resident's advance directive for a medical durable power of attorney. Resident #78's DNR (dated 05/09/17) documented that the resident was incapable of making informed decisions and that the patient had not executed a written advanced directive (living will or durable power of attorney). The DNR form was signed on 05/09/17 by the resident's physician and the resident's wife. The resident's advance directive was reviewed and documented that the advance directive was formulated on 07/10/2012. The resident's advance directive documented that the resident's medical durable power of attorney was the resident's daughter, not the resident's wife. A policy was requested and presented at this time. The policy titled, Advance Directives . documented, .forms will be reviewed and signed by the admitting physician dating the review .prior to, or upon admission, social services will provide resident with written information in a language that he or she can understand concerning the resident's rights .if an adult is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident's representative .changes or revocations of an advance directive must be submitted to social services .the attending physician will be responsible for issuing appropriate orders that coincide with the resident's advance directive . On 02/05/20 at approximately 4:00 PM, the DON (director of nursing) was interviewed and stated that the wife and the daughter share responsibilities. The DON was made aware that according to the resident's advance directive the resident's daughter is the authorized representative. No further information and/or documentation was presented prior to the exit conference on 02/06/20 to evidence that the facility staff followed written instruction of the resident's healthcare durable power of attorney.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and clinical record review, the facility failed to ensure a quarterly MDS (minimum data set) was completed timely for one of 21 Resident's. Resident #2 did not have a quarterly MDS completed within 92 days. The findings Include: Resident #2 was admitted to the facility on [DATE]. Diagnoses for Resident #2 included: Osteoporosis, pain, and anxiety. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/30/20. Resident #2 was assessed with a cognitive score of 15 indicating cognitively intact. Review of Resident #2's clinical record indicated Resident #2's comprehensive MDS with an ARD of 9/23/19 was completed on 10/1/19. Further review of Resident #2's MDS's indicated there was not an MDS completed within the 92 days following the comprehensive MDS. Documentation did show a quarterly MDS was created on 1/29/20 with an ARD of 1/30/20 and without a completion date. On 02/06/20 at 8:44 AM, RN #2 (MDS coordinator) was interviewed regarding the above findings. RN #2 stated that she was aware that the MDS was overdue, and that the MDS fell through the cracks due to human error and was currently being worked on to correct the MDS. On 02/06/20 at 9:30 AM, the above information was presented to the director of nursing and the assistant director of nursing. No other information was presented prior to exit conference on 2/6/20.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident interview, and staff interview, the facility staff failed to develop a person centered plan of care to address the residents' use of side rails for four of 21 residents in the survey sample, Residents # 14, 20, 21 and 36. The plan of care for each of the four residents had the same problem, goal, and interventions. The findings include: 1. Resident # 21 in the survey sample was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included cancer, hypertension, diabetes mellitus, hyperlipidemia, and depression. According to the most recent Minimum Data Set (MDS), a Quarterly review with an Assessment Reference Date (ARD) of 12/16/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. During the orientation tour at 10:20 a.m. on 2/4/2020, Resident # 21 was observed in street clothes, lying on the bed, sleeping. Both one-quarter bed rails, located at the head of the bed, were in the raised position. An empty urinal was hanging on one of the bed rails. At approximately 2:40 p.m. on 2/4/2020, Resident # 21 was interviewed regarding the one-quarter bed rails at the head of the bed. I use them to get in and out of bed, and to turn in bed, the resident said. Review of the facility's Side Rail Assessment form noted the resident was using the side (bed) rails for positioning and support. A Consent for the Utilization of Bed Side Rails(s) was signed by the resident on 5/26/17. Review of Resident # 21's plan of care, dated 8/13/18, revealed the following problem, Bedside rails. The goal for the problem was, Resident to maintain highest level of functioning. The interventions to the stated problem were, Has been educated on benefits of use; Use as directed for bed mobility and independence. During a meeting at 4:00 p.m. on 2/5/2020, that included the Director of Nursing, Assistant Director of Nursing, and the survey team, the lack of a person centered plan of care to address Resident # 21's bed rail use was discussed. 2. Resident # 20 in the survey sample was admitted to the facility on [DATE] with diagnoses that included hypertension, depression, obesity, obstructive sleep apnea, Non-Alzheimer's dementia, and [NAME]-Pick disease. According to an Annual MDS with an ARD of 12/19/19, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 12 out of 15. During the orientation tour at 10:25 a.m. on 2/4/2020, the resident was observed lying in bed sleeping. The head of the resident's bed was elevated to an approximately 30 degree angle. There was an inverted U type bed rail on each side of the head of the bed. At approximately 10:00 a.m. on 2/5/2020, the resident was interviewed about the use of the U bar bed rail. I use it to help me turn in bed, the resident said. Review of the facility's Side Rail Assessment form noted the resident was using the side (bed) rails for positioning and support. A Consent for the Utilization of Bed Side Rails(s) was signed by the resident on 11/14/18. Review of Resident # 20's plan of care, dated 8/14/18, revealed the following problem, Bedside rails. The goal for the problem was, Resident to maintain highest level of functioning. The interventions to the stated problem were, Has been educated on benefits of use; Use as directed for bed mobility and independence. 3. Resident # 36 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, congestive heart failure, hypertension, hyperlipidemia, conduct disorder, osteoporosis, cerebrovascular disease, hypothyroidism, depression, anxiety disorder, and Non-Alzheimer's dementia. According to a Quarterly review MDS with an ARD of 1/6/2020, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. During the orientation tour at 10:30 a.m. on 2/4/2020, the resident was observed seated in a reclining chair. The one-quarter bed rails at the head of the bed were in the lowered (down) position. Review of the facility's Side Rail Assessment form noted the resident was using the side (bed) rails for positioning and support. A Consent for the Utilization of Bed Side Rails(s) was obtained by telephone from the resident's spouse on 11/12/19. Review of Resident # 36's plan of care, dated 9/12/18, revealed the following problem, Bedside rails. The goal for the problem was, Resident to maintain highest level of functioning. The interventions to the stated problem were, Has been educated on benefits of use; Use as directed for bed mobility and independence. 4. Resident # 14 in the survey sample was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included a history of urinary tract infection, seizure disorder, chronic obstructive pulmonary disease, respiratory failure, difficulty walking, generalized muscle weakness, dysphagia, mild intellectual disabilities, hypothyroidism, hypocalcemia, and chronic pain syndrome. According to a Quarterly review MDS with an ARD of 12/2/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. The resident was out of the room during the orientation tour at 10:40 a.m. on 2/4/2020. The resident's bed had one-quarter bed rails at the head of the bed that were in the lowered (down) position. Review of the facility's Side Rail Assessment form noted the resident was using the side (bed) rails for positioning and support. A Consent for the Utilization of Bed Side Rails(s) was obtained by telephone from the resident's spouse on 5/4/18. Review of Resident # 14's plan of care, dated 9/5/18, revealed the following problem, Bedside rails. The goal for the problem was, Resident to maintain highest level of functioning. The interventions to the stated problem were, Has been educated on benefits of use; Use as directed for bed mobility and independence. At approximately 2:30 p.m. on 2/5/2020, RN # 1 and RN # 2 (Registered Nurse), both of whom identified themselves as MDS Coordinators, and as responsible for care plan development, were interviewed about Residents # 14, # 20, # 21 and # 36, and pointed out that the plan of care for bed rail use was not person centered and was exactly the same for each of the four residents. Neither RN # 1 nor RN # 2 could offer an explanation as to why the plans of care were not person centered, why they did not have measurable goals and objectives, and why all four were exactly the same.