Based on staff interview, facility document review, and clinical record review, the facility staff failed to inform a resident/resident representative of the risks, benefits, and alternatives of medication treatment for one of 13 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to inform the resident/resident representative of the risks, benefits, and alternatives of medication treatment for the use of the anti-anxiety medication lorazepam (used to treat anxiety). A review of R10's clinical record revealed a physician's order dated 2/12/25 for lorazepam 2mg/ml (milligrams/milliliters)- 0.25ml by mouth every four hours as needed for anxiety, sleeplessness, seizure activity or shortness of breath. Further review of R10's clinical record failed to reveal the facility staff informed the resident or the resident's representative of the risks, benefits, and alternative treatments for the use of lorazepam. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that when lorazepam is initiated, the resident and resident representative should be made aware of the targeted behaviors, side effects, black box warnings, and asked if they are aware of any alternative treatments that may work instead of the medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Resident Rights documented, 12. The Resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. No further information was presented prior to exit.

2. For Resident #10 (R10), the facility staff failed to notify the resident representative the resident was vomiting and placed on contact precautions on 2/19/25. A review of R10's clinical record revealed a nurse's note dated 2/19/25 that documented the resident was placed on contact isolation precautions due to vomiting during the previous day. Further review of R10's clinical record failed to reveal the resident's representative was notified regarding this change in condition on 2/18/25 or 2/19/25. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated a resident's representative should be made aware of the resident's change in condition as soon as possible and this is evidenced by documenting a nurse's note. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Change in a Resident's Condition documented, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status. No further information was presented prior to exit. Based on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to notify the physician or the responsible party of a change in condition for two of 13 residents in the survey sample, Residents #1 and #10. The findings include: 1. For Resident #1 (R1), the facility staff failed to notify the physician of complaints of burning and pain to the neck and the residents repeated request to call the on-call physician for treatment on 12/2/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/2/2025, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented no behaviors. On 6/3/25 at 1:30 p.m., an interview was conducted with R1 who stated that he had an area of skin cancer on his chest that was treated with a chemotherapy cream. R1 stated that a nurse had applied the chemotherapy cream to his neck by mistake and caused a chemical burn because it was only supposed to be applied to the cancer area on the chest. R1 stated that a few weeks after that the area on the neck started burning and hurting and he had asked the evening nurse to call the on-call physician, and she had refused to call. He stated that the nurse told him that it was not an emergency and that he did not have an order for the hydrocortisone cream that he was requesting, and she would put it in the book for the nurse practitioner the next day. R1 stated that he had told her that it was an emergency to him and asked her to call the on-call doctor for an order for hydrocortisone but she stated that there was nothing on his neck and it was not an emergency. He stated that the nurse came in twice more during the night and kept telling him that there was no order for the hydrocortisone and that she was not going to call the on-call physician to get one because his neck was fine every time he asked her to call. The progress notes for R1 documented in part, - 12/02/2024 19:30 (7:30 p.m.) Note Text: Writer approached by resident to apply cream to neck (hydrocortisone cream) stating my neck is burning from my chemical burn I received over 2 weeks ago. Writer then assessed area, no visible marks were apparent to resident's neck area, no redness no swelling nor visible irritation. Writer then assessed resident active orders and notes and notified resident that per active orders and from derm (dermatology) note. Hydrocortisone is not to start until 12/12. Also, that resident and RP (responsible party) was made aware and agreeable to this order. Resident then insisted that I notify the on-provider for non-emergent request. Writer advised resident that this request would be placed in Np (nurse practitioner) communication book. Resident then stated to writer No you need to call the DON (director of nursing) and On-call now cause I have their numbers, and I will contact them, writer then replied that he could contact anyone, but as a licensed nurse and after hours I did not see nor note any emergency to notify on-call for hydrocortisone cream. Resident's vital were obtained WNL (within normal limits), resident not in any distress during any assessment, resident was assessed through entire shift, resident also made aware that if any changes were noted that appeared emergent I would notify On-call. - 12/03/2024 01:39 (1:39 a.m.) Note Text: Resident received scheduled medication as order, Vital obtained, WNL (within normal limits), no redness, irritation, nor swelling noted. Resident noted with skin area to chest as noted only. Neck area dry and intact. Will continue to monitor. - 12/03/2024 03:39 (3:39 a.m.) Note Text: Writer enters room for reassessment to neck area; resident had complaints of burning and pain to area. At this time, no redness, swelling, irritation noted to area. Resident noted in bed with eyes closed during entering of room. Resident appeared to be in no distress. No further complaints made during time since last assessment, no further request made at this time. Resident became upset and irate raising voice, when resident asked writer if I had located and read Derm not [sic] from 10/21 writer advised resident yes at this time, and that there areas that needs clarification and that this matter would be passed on to [Name of former unit manager] in the am for follow as the dermatologist office is closed at this time. 12/03/2024 07:05 (7:05 a.m.) Note Text: Writer enters resident room for medication administration, neck assessed, no irritation, no swelling, redness noted to area. Resident updated on status. Continues to state that neck has chemical burn. UM (unit manager) notified of issues and concerns. Medication administered and accepted without difficulty. VS WNL (vital signs within normal limits) at this time. - 12/03/2024 14:05 (2:05 p.m.) Note Text: Hydrocortisone External Gel 1 % Apply to neck topically as needed for as needed for neck burning for 7 Days. On 6/4/25 at 3:33 p.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that there was an on-call provider available after 7:00 p.m. each day and on weekends. She stated that the staff had a protocol that they followed for calling the on-call provider and had standing orders that they were able to implement for some things. She stated that any non-emergent issues that could wait until the next day were put in the provider book for follow up the next day. LPN #8 provided a printed paper that she stated hung at the nurse's station which contained a stop sign and contained procedures that addressed when to call the on-call provider. When asked if a resident was requesting for the on-call provider to be called due to complaints of skin burning and pain, LPN #8 stated that the nurse should call the on-call provider because it was the residents right. On 6/4/25 at 3:59 p.m., an interview was conducted with ASM (administrative staff member) #3, nurse practitioner. ASM #3 stated that she followed R1 at the facility since November 2024 but was not completely familiar with the cream he was receiving and never saw the chemical burn on his neck. She stated that she did see him on 12/3/24 when he complained of burning but it looked healthy. ASM #3 stated that she was in the facility Monday through Friday and staff could call her until 7:00 p.m. and after that they called the on-call provider. She stated that the criteria for calling the on-call provider was if a resident needed medications, had acute problems, was having shortness of breath or any new or acute symptoms. She stated that she felt it would be a case-by-case situation and R1 was insistent that he needed the Hydrocortisone for his neck, so she had prescribed it but felt that medically there was no need for it. She stated that as far as whether the nurse called the on-call provider she could not speak to that. On 6/5/25 at 11:06 a.m., an interview was conducted with LPN #5 who stated that R1 had complained of his neck burning and hurting on 12/2/24 when she was caring for him. She stated that R1 had not had any treatment to the neck for about a week and a half, so she had assessed the area and did not see any marks, so she put it in the book for the nurse practitioner to follow up the next day. She stated that R1 wanted her to call the on-call physician, but she felt that she did not need to call, and she told him that she would go in and check him every two hours to make sure the area did not change. She stated that she had called the unit manager and the director of nursing at the time, and they said they would assess his neck the next morning. The facility policy Change in a Resident's Condition documented in part, Policy: The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . On 6/5/25 at 2:47 p.m., ASM #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the above concern. No further information was obtained prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to review or revise the comprehensive care plan for one of 13 residents, Residents in the survey sample, Resident #11 (R11). The findings include: For R11, the facility staff failed to review or revise comprehensive care plan following a fall on 03/10/2025. R11 was admitted to the facility with diagnosis that included but was not limited to dementia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/14/2024, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating R11 was severely impaired of cognition for making daily decisions. The facility's nursing note for R11 dated 03/10/2025 documented, Writer was informed by activities worker that resident was on floor. writer went in room with cna (certified nursing assistant). resident was lying on floor, alert and oriented, resident did not hit head, no bruising lacerations or bleeding, neuro checks in place per facility policy, resident was placed back in bed, call bell within. RP (responsible party) was left a voicemail and notified ADON (assistant director of nursing) and provider about fall, vital signs obtained per facility protocol. no new orders were given. The facility's fall investigation for R11 dated 03/10/2025 documented in part, Incident description Writer was informed by activities worker that resident was on floor. writer went in room with cna. resident was lying on floor, alert and oriented, resident did not hit head, no bruising lacerations or bleeding, neuro checks in place per facility policy, resident was placed back in bed, call bell within. RP was left a voicemail and notified ADON (assistant director of nursing) and provider about fall, vital signs obtained per facility protocol. no new orders were given. Was this incident witnessed: N (no). Injury Type: No injuries observed at time of incident. Review of R11's comprehensive care plan with a revision date of 02/05/2025 failed to evidence documentation of R11's fall on 03/23/2024. On 06/05/2025 at approximately 2:45 p.m., an interview was conducted with RN (registered nurse) #4, MDS coordinator. When asked to describe the procedure regarding a resident's care plan following a fall she stated that the care plan is review after each fall and revisions are made if they are needed. After reviewing R11's fall care plan RN #4 stated that a revision was not needed but it was reviewed. When asked for the documentation or evidence that the care plan was reviewed regarding R11's fall on 03/10/2025, she stated that there was no documentation of a review. The facility's policy Care Planning - Comprehensive Person-Centered documented in part, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: b. When there has been a significant change in the resident's condition; On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.

Based on observation, staff interview, clinical record review, and facility, it was determined that facility staff failed to provide respiratory care and services for one of 13 residents in the survey sample, Resident #5 (R5). For R5, the facility staff failed to obtain a physician's order for the use of oxygen. The findings include: R5 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/23/2025, R5 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R5 was cognitively intact for making daily decisions. On 06/03/2025 at approximately 12:25 p.m. an observation revealed R5 receiving oxygen at three liters per minute by nasal cannula (2). The physician's order for R5 dated 06/03/2025 documented in part, Oxygen 3 (three) via (by) NC (nasal cannula) continuous. Order Date: 06/03/2025. Audit Details. Created Date: 06/03/2025. 1445 (2:45 p.m.). On 06/04/2025 at approximately 3:00 p.m. an interview was conducted with RN 9registered nurse) #1, unit manager. When informed of the observation of R5 receiving oxygen as stated above, RN #1 stated that there was no physician's order for R5's oxygen at the time of the surveyor's observation. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (2) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for three of 13 residents in the survey sample, Residents #1, #5, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R1 resided on the [NAME] unit. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day for nasal congestion. 6/16/24-Magnesium Oxide 400mg-one tablet by mouth two times a day for rhabdomyolysis (skeletal muscle breakdown). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Pseudoephedrine was scheduled at 7:00 a.m. and was administered at 12:34 p.m. -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Azelastine was scheduled at 7:00 a.m. and was administered at 12:35 p.m. -Magnesium Oxide was scheduled at 7:00 a.m. and was administered at 12:33 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. LPN #2 stated she called ASM (administrative staff member) #3 (the nurse practitioner) and told her she was the only nurse on the [NAME] unit and medications were going to be late. LPN #2 stated ASM #3 said she could not give orders for everybody, and LPN #2 would have to use her nursing judgement and critical thinking. LPN #2 stated she administered medications to every resident on the unit using her best judgment. LPN #2 stated she could not administer medications that were ordered three times a day because the medications were administered late, and the medications would be given too close to the next dose. On 6/4/25 at 4:14 p.m., an interview was conducted with ASM #3. ASM #3 stated that on 12/25/24, LPN #2 called her and told her she was behind on the medication pass. ASM #3 stated she did not remember the details of what she and LPN #2 discussed and did not document any notes. ASM #3 stated she did not remember if she and LPN #2 discussed each resident, but they discussed important medications that could not be missed. ASM #3 stated she would have to refer to LPN #2 on who they discussed. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is not optimal to have missed or late medications. OSM #7 stated some medications work over such a long period of time and some medications are more critical. OSM #7 stated when some critical medications are missed or late, there could be serious adverse effects, and this depends on each person and each medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Physician Services documented, 1. The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. No further information was presented prior to exit. 2. For Resident #5 (R5), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R5 resided on the [NAME] unit. A review of R5's clinical record revealed the following physician's orders: 1/29/24-hydralazine 50mg (milligrams)-one tablet by mouth three times a day for high blood pressure. 12/18/24-Brimonidine Tartrate 0.2%- one drop in the left eye two times a day for increased eye pressure. A review of a medication administration audit report for 12/25/24 revealed the following: -hydralazine was scheduled at 7:00 a.m. and was administered at 10:36 a.m. -hydralazine was scheduled at 11:00 a.m. and was administered at 2:42 p.m. -Brimonidine Tartrate was scheduled at 7:00 a.m. and was administered at 10:36 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. LPN #2 stated she called ASM (administrative staff member) #3 (the nurse practitioner) and told her she was the only nurse on the [NAME] unit and medications were going to be late. LPN #2 stated ASM #3 said she could not give orders for everybody, and LPN #2 would have to use her nursing judgement and critical thinking. LPN #2 stated she administered medications to every resident on the unit using her best judgment. LPN #2 stated she could not administer medications that were ordered three times a day because the medications were administered late, and the medications would be given too close to the next dose. On 6/4/25 at 4:14 p.m., an interview was conducted with ASM #3. ASM #3 stated that on 12/25/24, LPN #2 called her and told her she was behind on the medication pass. ASM #3 stated she did not remember the details of what she and LPN #2 discussed and did not document any notes. ASM #3 stated she did not remember if she and LPN #2 discussed each resident, but they discussed important medications that could not be missed. ASM #3 stated she would have to refer to LPN #2 on who they discussed. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is not optimal to have missed or late medications. OSM #7 stated some medications work over such a long period of time and some medications are more critical. OSM #7 stated when some critical medications are missed or late, there could be serious adverse effects, and this depends on each person and each medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit. 3. For Resident #9 (R9), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R9 resided on the [NAME] unit. A review of R9's clinical record revealed the following physician's orders: 6/15/23-tramadol 50mg (milligrams)-one tablet by mouth three times a day for pain. 9/7/24-Miralax 17 grams by mouth two times a day for constipation. A review of a medication administration audit report for 12/25/24 revealed the following: -tramadol was scheduled at 9:00 a.m. and was administered at 10:59 a.m. -Miralax was scheduled at 9:00 a.m. and was scheduled at 11:00 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. LPN #2 stated she called ASM (administrative staff member) #3 (the nurse practitioner) and told her she was the only nurse on the [NAME] unit and medications were going to be late. LPN #2 stated ASM #3 said she could not give orders for everybody, and LPN #2 would have to use her nursing judgement and critical thinking. LPN #2 stated she administered medications to every resident on the unit using her best judgment. LPN #2 stated she could not administer medications that were ordered three times a day because the medications were administered late, and the medications would be given too close to the next dose. On 6/4/25 at 4:14 p.m., an interview was conducted with ASM #3. ASM #3 stated that on 12/25/24, LPN #2 called her and told her she was behind on the medication pass. ASM #3 stated she did not remember the details of what she and LPN #2 discussed and did not document any notes. ASM #3 stated she did not remember if she and LPN #2 discussed each resident, but they discussed important medications that could not be missed. ASM #3 stated she would have to refer to LPN #2 on who they discussed. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is not optimal to have missed or late medications. OSM #7 stated some medications work over such a long period of time and some medications are more critical. OSM #7 stated when some critical medications are missed or late, there could be serious adverse effects, and this depends on each person and each medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide sufficient nursing staff for three of 13 residents in the survey sample, Residents #1, #5, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R1 resided on the [NAME] unit. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day for nasal congestion. 6/16/24-Magnesium Oxide 400mg-one tablet by mouth two times a day for rhabdomyolysis (skeletal muscle breakdown). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Pseudoephedrine was scheduled at 7:00 a.m. and was administered at 12:34 p.m. -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Azelastine was scheduled at 7:00 a.m. and was administered at 12:35 p.m. -Magnesium Oxide was scheduled at 7:00 a.m. and was administered at 12:33 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. On 6/5/25 at 8:52 a.m., an interview was conducted with OSM (other staff member) #6 (the nursing scheduler). OSM #6 stated two nurses should work on the [NAME] unit during the day shift. OSM #6 stated she thought two nurses were scheduled for the [NAME] unit during the day shift on 12/25/24 and something happened but she would check. OSM #6 reviewed her computerized scheduling application and stated it would not allow her to review how many nurses were scheduled for the [NAME] unit during the day shift on 12/25/24. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Staffing documented, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. No further information was presented prior to exit. 2. For Resident #5 (R5), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R5 resided on the [NAME] unit. A review of R5's clinical record revealed the following physician's orders: 1/29/24-hydralazine 50mg (milligrams)-one tablet by mouth three times a day for high blood pressure. 12/18/24-Brimonidine Tartrate 0.2%- one drop in the left eye two times a day for increased eye pressure. A review of a medication administration audit report for 12/25/24 revealed the following: -hydralazine was scheduled at 7:00 a.m. and was administered at 10:36 a.m. -hydralazine was scheduled at 11:00 a.m. and was administered at 2:42 p.m. -Brimonidine Tartrate was scheduled at 7:00 a.m. and was administered at 10:36 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. On 6/5/25 at 8:52 a.m., an interview was conducted with OSM (other staff member) #6 (the nursing scheduler). OSM #6 stated two nurses should work on the [NAME] unit during the day shift. OSM #6 stated she thought two nurses were scheduled for the [NAME] unit during the day shift on 12/25/24 and something happened but she would check. OSM #6 reviewed her computerized scheduling application and stated it would not allow her to review how many nurses were scheduled for the [NAME] unit during the day shift on 12/25/24. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. 3. For Resident #9 (R9), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R9 resided on the [NAME] unit. A review of R9's clinical record revealed the following physician's orders: 6/15/23-tramadol 50mg (milligrams)-one tablet by mouth three times a day for pain. 9/7/24-Miralax 17 grams by mouth two times a day for constipation. A review of a medication administration audit report for 12/25/24 revealed the following: -tramadol was scheduled at 9:00 a.m. and was administered at 10:59 a.m. -Miralax was scheduled at 9:00 a.m. and was scheduled at 11:00 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. On 6/5/25 at 8:52 a.m., an interview was conducted with OSM (other staff member) #6 (the nursing scheduler). OSM #6 stated two nurses should work on the [NAME] unit during the day shift. OSM #6 stated she thought two nurses were scheduled for the [NAME] unit during the day shift on 12/25/24 and something happened but she would check. OSM #6 reviewed her computerized scheduling application and stated it would not allow her to review how many nurses were scheduled for the [NAME] unit during the day shift on 12/25/24. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to resolve grievances voiced regarding linen supplies in 10 of 11 months of resident council meetings reviewed. The findings include: The facility staff failed to resolve ongoing grievances regarding shortages of washcloths and towels voiced during resident council meetings in 10 of 11 months reviewed. On 6/3/25 at 1:30 p.m., an interview was conducted with Resident #1 (R1) who stated that there was an ongoing problem with a lack of towels and washcloths at the facility. R1 stated that often the night shift did not have enough linens to get people up and they had to wait for the day shift to get them up when the linens were delivered. R1 stated that often the day shift had to wait for the linens to be delivered before they could get residents up and some were not able to get to the dining room for breakfast because of this. R1 stated that the facility had stopped using disposable wipes for incontinence care and the staff were using wash cloths now which was causing a shortage. On R1's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/2/25, the resident was assessed as being cognitively intact for making daily decisions. On 6/3/25 at 2:58 p.m., an interview was conducted with Resident #9 (R9) who stated that the care at the facility depended on who was working and there were days when it took a while for them to get her out of bed. R9 stated that there were problems with a lack of towels and washcloths at the facility and they talked about it in their meetings. On R9's most recent MDS assessment, an annual assessment with an ARD of 5/13/25, the resident was assessed as being cognitively intact for making daily decisions. On 6/4/25 at 1:09 p.m., an interview was conducted with Resident #13 (R13) who stated that staff had advised her that she was allowed one towel and one washcloth per day. R13 stated that she did not understand why the staff were so stingy with them. On R13's most recent MDS assessment, an admission assessment with an ARD of 4/8/25, the resident was assessed as being moderately impaired for making daily decisions. Review of the facility resident council minutes documented in part, - 7/10/24 . would like more towels - 8/14/24 . Need washcloths and sheets . A Grievance/Suggestion Communication form dated 8/14/24 documented in part, 8/15/24 wash cloths have been ordered . - 10/9/24 . We're running out of towels, rags, and washcloths . A Grievance/Suggestion Communication form dated 10/9/24 documented in part, . The closets are filled 2 times daily and linen is being hoarded. DON (director of nursing) addressed issue in a meeting on 10/10 . - 11/13/24 . residents are requesting more washcloths and linens . Most residents would like to be up and in their real [sic] chairs earlier to attend activities . - 12/11/24 . no washcloths, bathing times delayed . A Grievance/Suggestion Communication form dated 12/11/24 documented in part, .There were complaints that there were no washcloths, which caused their bathing times to be delayed. [Name of environmental services (EVS) director] explained that the matter was being handled, and they were in the process of figuring out who is hoarding the clean linen. The matter is being taken care of . Follow up action: Continue to do a closet fill up on each unit 2-3 times a day to accommodate residents and continue to educate nursing staff on hoarding issue . - 1/8/25 . There were complaints that there were no washcloths, which caused their bathing times to be delayed. [Name of EVS director] explained that the matter was being handled, and they were in the process of figuring out who is hoarding the clean linen. He stated laundry was found in certain rooms in the closets and under the beds. The matter is being taken care of. [Name of EVS director] also shared that new washing machine had been ordered . A Grievance/Suggestion Communication form dated 1/8/25 documented in part, .There were complaints that there were no washcloths, [Name of EVS director] explained that the matter was being handled, and they were in the process of figuring out who it is hoarding clean linen was located in bags on [NAME]. It was found in closets and under the beds, the matter is being taken care of . - 2/26/25 . beds are not getting changed in a timely manner. There is bathing schedule delay due to lack of clean towels . A Grievance/Suggestion Communication form dated 2/26/25 documented in part, .Beds are not getting changed in a timely manner. [Name of R1] states you can't get bath because there's no clean towels . It documented the concern referred to nursing, laundry, housekeeping and dietary department. - 3/13/25 . They would like more washcloths . A Grievance/Suggestion Communication form dated 3/19/25 failed to evidence documentation regarding washcloth concerns. - 4/9/25 . They would like more washcloths . A Grievance/Suggestion Communication form dated 4/9/25 failed to evidence concerns regarding washcloths. - 5/28/25 . issues with getting washcloths, pads & towels . There were no grievance/suggestion communication forms regarding the resident council concerns regarding washcloths, pads & towels. On 6/3/25 at 4:03 p.m., an interview was conducted with OSM (other staff member) #12, LTC (long term care) ombudsman. OSM #12 stated that she had been working with the facility for quite a while to try to get the linen shortages fixed for the residents. She stated that she attended the resident council meetings by invitation from the residents and they complained every month about a lack of towels, washcloths and pads. OSM #12 stated that baths, showers and getting residents out of bed were delayed due to a lack of linens. She stated that she had conducted spot checks in the linen closets and would find no linen available. OSM #12 stated that when she asked she was told that the aides were stealing the linens, then she was told that they were hoarding them in the rooms. She stated that she did rounds with the director of environmental services and checked resident rooms where they suspected linens were being hoarded and found nothing. OSM #12 stated that she spoke to residents, and no one knew of any hoarding areas for linen. She stated that the facility had stopped using disposable wipes a while back and staff were using washcloths for incontinence care which had drastically increased the usage and demand. On 6/4/25 between 8:47 a.m. and 9:04 a.m. observations were made of the facility unit linen closets. The findings included the following: - Grace unit (30 beds) linen closet 18 washcloths and 23 towels available. - [NAME] unit (60 beds) linen closet 16 washcloths and 9 towels available. - [NAME] unit (30 beds) linen closet 18 washcloths and 16 towels available. On 6/4/25 at 9:13 a.m. an observation of the laundry clean linen area revealed 25 towels and no washcloths on the shelf. On 6/4/25 at 8:50 a.m., an interview was conducted with CNA (certified nursing assistant) #2 who stated that there were times when they ran out of linens. She stated that when they ran out they went to the laundry and asked for more. CNA #2 stated that they used to have disposable wipes for incontinence care, but they stopped using them and now they used washcloths and towels which caused them to use a lot. She stated that she could not say it made the job harder, but it took more washcloths to clean the resident if they had large bowel movements and she would not want to put the washcloth on her face after that even if it had been washed. She stated that she has had residents that were not able to be gotten out of bed on the night shift due to a lack of linens. On 6/4/25 at 8:56 a.m., an interview was conducted with CNA #6 who stated that the linen was normally stocked in the morning between 8-9 am. She stated that there were times when she ran out of towels and washcloths, but she went to laundry to get more as needed. On 6/4/25 at 12:25 p.m., an interview was conducted with CNA #5 who stated that they used washcloths and towels for incontinence care and bathing of residents. She stated that all linens were sent to the laundry for cleaning, and they disposed of anything that was too soiled to be washed. CNA #5 stated that there were times when they ran out of linens, and they had to call the laundry to bring more up or go down to get more linens. She stated that usually they came within 15 minutes, but residents had to wait until they got the linens to provide the care. CNA #5 stated that this morning the linen closet was stocked when she arrived, but this was unusual because it was not always stocked during the day. She stated that she had some residents who had their bathing or getting out of bed delayed due to a lack of linens. CNA #5 stated that she was not aware of any staff who threw away soiled linens or hoarded them. She stated that she had received report a couple of times from the night shift saying that they could not get a resident up because they did not have any linen and that was within the past four months. On 6/4/25 at 9:05 a.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that in the past they recalled concerns from residents about not being able to get up due to a lack of towels and washcloths, but they had educated the laundry, and they were doing much better and stocking twice a day before the shift change. On 6/4/25 at 9:13 a.m., an interview was conducted with OSM #5, the director of environmental services who stated that they had been working at the facility since February of 2024. She stated that the linen situation was in dire straits when she first started, and she had been working to resolve the issues. OSM #5 stated that she kept a supply of new towels and washcloths as a backup for emergencies in the back of the laundry and in her office. She stated that the staff used the washcloths as wipes, and she found that some of the aides were throwing them away in the trash. OSM #5 stated that starting in April 2025 she had hired a night shift laundry person to stock the closets in the mornings to see if that would help the situation. She stated that she had conducted some room audits which found some hoarded linens in resident rooms and she had worked with the unit managers to educate the staff. On 6/4/25 at 4:20 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that since she started working at the facility in February 2025 they had done a lot of education and monitoring of the linen. She stated that they had found that the staff were throwing soiled linens in the trash and they had started ordering more. She stated that they also found that staff were hoarding linens in rooms and other employees were not aware where the linen was. ASM #2 stated that they had taken it upon themselves to try to continuously replenish the laundry on the floors. On 6/5/25 at 9:26 a.m., an interview was conducted with OSM #11, acting activities director. OSM #11 stated that she did not attend the resident council meetings but she understood that the former activities director used to go to the resident council meetings, write down any concerns and the communicate them to the appropriate department by the grievance form. She stated that the residents often complain to her that the laundry runs out of towels and washcloths and the staff do not have any available to get them up and dressed. OSM #11 stated that the residents had complained recently to her about delays in getting up due to linens not being available. On 6/5/25 at 12:53 p.m., an interview was conducted with ASM #1, administrator who stated that since she had been in the position she has made sure that towels and washcloths were ordered at least once a month. She stated that she had created a form that the CNAs could carry that asked them if they had enough linen and she did that for a month or two. She stated that she rounded in the mornings to see if there were washcloths, towels and everything they needed on the units. ASM #1 stated that she had asked EVS to hire the night laundry person. She stated that the housekeeping director thought that the staff were throwing away the washcloths and towels and she continued to authorize the orders for additional linens and was not aware of any current issues. Review of facility invoices for towel and washcloth orders documented orders placed on 7/19/24, 8/8/24, 12/6/24, 12/19/24, 1/16/25, 2/18/25, 3/12/25, 4/15/25, and 5/13/25. The facility policy Resident Rights documented in part, . The resident has the right to and the facility must make prompt efforts to resolve grievances the resident may have . On 6/5/25 at 2:47 p.m., ASM #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the concern. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 13 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to ensure the physician documented the duration for the use of prn (as needed) lorazepam and failed to attempt non-pharmacological interventions prior to the administration of prn lorazepam. A review of R10's clinical record revealed a physician's order dated 2/12/25 for lorazepam 2mg/ml (milligrams/milliliters)- 0.25ml by mouth every four hours as needed for anxiety, sleeplessness, seizure activity or shortness of breath. A nurse practitioner note dated 4/1/25 documented, Continue Lorazepam, this is a PRN, she doesn't need it very often but she does need it due to her schizophrenia. Further review of R10's clinical record failed to reveal nurse practitioner or physician documentation regarding the intended duration of use for prn lorazepam. A review of R10's MARs (medication administration records) for February 2025, March 2025, and May 2025 revealed the resident was administered prn lorazepam on 2/14/25, 3/6/25, 3/9/25, and 5/20/25. Further review of R10's clinical record (including the MARs and nurses' notes for those dates) failed to reveal the facility staff attempted non-pharmacological interventions prior to the administration of prn lorazepam on those dates. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated she did not know what the physician should document regarding the use of prn lorazepam. On 6/5/25 at 10:01 a.m., another interview was conducted with RN #1. RN #1 stated non-pharmacological interventions should be individualized and should be attempted prior to the administration of prn lorazepam. RN #1 stated nurses should evidence the attempt of non-pharmacological interventions by documenting a progress note. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Antipsychotic Medication Use documented, 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for four of 13 residents in the survey sample, Residents #1, #5, #7, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day for nasal congestion. 5/13/24-Simvastatin 40mg-one tablet by mouth at bedtime for high cholesterol. 6/16/24-Magnesium Oxide 400mg-one tablet by mouth two times a day for rhabdomyolysis (skeletal muscle breakdown). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Pseudoephedrine was scheduled at 7:00 a.m. and was administered at 12:34 p.m. -Pseudoephedrine was scheduled at 8:00 p.m. and was administered at 10:08 p.m. -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Azelastine was scheduled at 7:00 a.m. and was administered at 12:35 p.m. -Azelastine was scheduled at 8:00 p.m. and was administered at 10:07 p.m. -Simvastatin was scheduled at 8:00 p.m. and was administered at 10:08 p.m. -Magnesium Oxide was scheduled at 7:00 a.m. and was administered at 12:33 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Medication Administration documented, 14. Medications are administered within 60 minutes of scheduled time . No further information was presented prior to exit. 2. For Resident #5 (R5), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R5's clinical record revealed the following physician's orders: 1/29/24-hydralazine 50mg (milligrams)-one tablet by mouth three times a day for high blood pressure. 11/19/24-Carvedilol 3.125mg by mouth two times a day for high blood pressure. 12/18/24-Brimonidine Tartrate 0.2%- one drop in the left eye two times a day for increased eye pressure. A review of a medication administration audit report for 12/25/24 revealed the following: -hydralazine was scheduled at 7:00 a.m. and was administered at 10:36 a.m. -hydralazine was scheduled at 11:00 a.m. and was administered at 2:42 p.m. -hydralazine was scheduled at 8:00 p.m. and was administered at 9:43 p.m. -Carvedilol was scheduled at 6:00 p.m. and was administered at 9:43 p.m. -Brimonidine Tartrate was scheduled at 7:00 a.m. and was administered at 10:36 a.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit. 3. For Resident #7 (R7), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R7's clinical record revealed the following physician's orders: 5/28/24-levetiracetam 500mg (milligrams) by mouth two times a day for seizure like activity. 10/26/24-Tylenol 500mg-two tablets by mouth two times a day for pain. A review of a medication administration audit report for 12/25/24 revealed the following: -levetiracetam was scheduled at 5:00 p.m. and was administered at 11:07 p.m. -Tylenol was scheduled at 5:00 p.m. and was administered at 11:07 p.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit. 4. For Resident #9 (R9), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R9's clinical record revealed the following physician's orders: 6/15/23-tramadol 50mg (milligrams)-one tablet by mouth three times a day for pain. 2/18/24-Diclofenac 1% gel-apply to shoulder and neck two times a day for arthritic pain. 9/7/24-Miralax 17 grams by mouth two times a day for constipation. A review of a medication administration audit report for 12/25/24 revealed the following: -tramadol was scheduled at 9:00 a.m. and was administered at 10:59 a.m. -Diclofenac was scheduled at 6:00 p.m. and was administered at 10:05 p.m. -Miralax was scheduled at 9:00 a.m. and was scheduled at 11:00 a.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of 13 residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to provide personal hygiene on multiple shifts in March 2025 and May 2025. A review of R8's ADL records for March 2025 and May 2025 failed to reveal personal hygiene (combing hair, brushing teeth, washing/drying face and hands) was provided on the following dates/shifts (as evidenced by blank spaces on the records): 3/10/25 during the day shift. 3/17/25 through 3/20/25 during the evening shift. 3/22/25 through 3/23/25 during the evening shift. 5/17/25 during the day shift. On 6/4/25 at 2:23 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated personal hygiene consists of mouth care, nail care, perineal care, and washing under residents' arms/applying deodorant. CNA #2 stated residents' bodies should be washed once per shift, mouth care should be done in the morning and after each meal, and she washes under residents' nails if their nails are dirty. CNA #2 stated CNAs evidence personal hygiene was provided by documenting this every shift in the ADL records. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Activities of Daily Living (ADLs) documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure one of 13 residents in the survey sample was free of significant medication errors, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to ensure they were free of significant medication errors A) on 11/8/24 when fluorouracil 5% cream (1) was applied to the neck when it was supposed to be applied to the chest and B) on 9/27/23, 11/19/23, and 5/31/24 when Debrox (2) ear drops were administered into the eye and C) on 12/25/24 when Baclofen 20mg (3) was administered late. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/2/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment documented R1 receiving scheduled pain medication. On 6/3/25 at 1:30 p.m., an interview was conducted with R1 who stated that he went to the dermatologist who had frozen a spot on his chest and when he went back for the follow up visit they had ordered a chemotherapy cream. R1 stated that LPN (licensed practical nurse) #9 had applied the chemotherapy cream to his neck rather than the skin cancer lesion on his chest and caused a reddened area that was treated with hydrocortisone. R1 stated that he had multiple problems with ear wax buildup in the right ear and had Debrox ordered multiple times to soften the ear wax. He stated that there were three times when nurses had administered the ear drops into his eye which caused it to burn like fire and was painful. A) The facility staff failed to administer fluorouracil 5% cream to the correct location on 11/8/24. The physician orders for R1 documented in part, - Fluorouracil External Cream 5 % (Fluorouracil (Topical)) Apply to spot on left chest topically two times a day for actinic keratosis for 3 Weeks apply a thin film only on the spot. Stop for open sores, pain, or bleeding even if they develop before 3 weeks. But redness and scabbing is expected. Leave open to air. Pregnant women should avoid admin. Order Date: 10/30/2024. Start Date: 10/30/2024. The progress notes for R1 documented in part, - 11/08/2024 11:02 (11:02 a.m.) Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition . Nursing observations, evaluation, and recommendations are: the fluorouracil 5% cream was applied to spot on the left side of neck when it was supposed to be applied to left chest. Redness noted and resident c/o (complains of) slight burning feeling. Md office called and new order obtained for hydrocortisone 2.5% ointment bid x 1 week . - 11/08/2024 11:19 (11:19 a.m.) Note Text: Residents wife updated on new order for red spot on residents left side of his neck. On 6/4/25 at 2:17 p.m., an interview was conducted with RN (registered nurse) #1 who stated that prior to medication administration the nurse checked the physician order with the medication itself and followed the five rights of medication administration (right medication, right time, right dose, right person, right route). She stated that they also documented the medication as administered. On 6/5/25 at 9:35 a.m., an interview was conducted with LPN (licensed practical nurse) #9 who stated that the fluorouracil cream had been applied to R1's neck and caused an irritated area which they treated with hydrocortisone cream. LPN #9 stated that the fluorouracil cream was supposed to be applied to the skin cancer area on the chest. On 6/5/25 at 12:37 p.m., an interview was conducted with OSM (other staff member) #7, pharmacist who stated that fluorouracil cream was used for skin lesions and skin cancer. She stated that the usage was to apply sparingly just to the area being treated by the physician, wearing gloves when applying and covering loosely to contain the cream. She stated that since it was used to treat cancer some thought of it as a chemotherapy drug but if it was used appropriately there was no concern. OSM #7 stated that normal gloves were indicated when applying the cream and pregnant women should avoid coming in contact with it. She stated that the cream should only be applied to the skin lesion being treated because it was used to disrupt the cells and used to kill the cancer cells. OSM #7 stated that if the cream was applied to healthy skin it would cause irritation, redness and pain would be subjective to the resident. B) The facility staff failed to administer Debrox ear drops correctly on 9/27/23, 11/19/23, and 5/31/24. The physician orders for R1 documented in part, - Debrox Solution 6.5 % (Carbamide Peroxide) Instill 5 drop in right ear two times a day for excess cerumen for 4 Days. Start Date: 09/26/2023. - Debrox Otic Solution 6.5 % (Carbamide Peroxide (Otic)) Instill 5 drop in right ear two times a day for cerumen impaction for 3 Days x 3 days until irrigation performed per NP (nurse practitioner). Start Date: 11/18/2023. - Debrox Solution 6.5 % (Carbamide Peroxide) Instill 5 drop in both ears two times a day for Cerumen for 4 Days. Start Date: 05/29/2024. Review of the facility medication error report for R1 dated 11/19/23 documented in part, Per [Name of staff member], she took Debrox ear drops out of the Tears eye drop box and did not check the label on the vial and then proceeded put debrox in res L-eye .Nurse immediately flushed res eye with NS (normal saline). Supervisor spoke with resident's wife and then spoke with FNP (family nurse practitioner) and received new orders which were initiated. Res denied any pai [sic] at that time . A report dated 9/29/23 documented in part, The nurse on shift administered Debrox ear drops in the residents' eyes instead of Natural Tears drops to the residents' eyes on the evening of 9/27/23. The resident reported to this writer (DON) (director of nursing) that when he received his eye drops on the evening of 9/27/23 when the drops were administered the drops burned his eyes. He reported this to the nurse and she flushed his eyes immediately. The resident stated that his eyes were sore and a little blurry .This error was reported to the NP and the resident's eyes was assessed and there was no redness at that time but he resident did state his eyes were a little sore and a little blurry. There were no further adverse reactions noted . A report dated 5/31/24 documented in part, Nurse in patient's room administering morning medications. The patient requested his eye drops, and his ear drops. The patient's eye drops were placed in the ear drops container and the ear drops were placed in the eye drops box. Nurse grabbed both containers while talking with the patient concerning his medications and his care. Nurse accidentally placed ear drops in the patients left eye. Patient complained about his left eye is burning. Nurse flushed the patient's left eye with a large amount of water . Patient's eyes flushed with large amounts of water. Patient stated his eye is fine. Nurse applied artificial tears to the patient's left eye. Patient states his eye feels better, and he is able to see out of his left eye without difficulty . On 6/4/25 at 2:17 p.m., an interview was conducted with RN (registered nurse) #1 who stated that prior to medication administration the nurse checked the physician order with the medication itself and followed the five rights of medication administration (right medication, right time, right dose, right person, right route). She stated that they also documented the medication as administered. On 6/5/25 at 12:37 p.m., an interview was conducted with OSM (other staff member) #7, pharmacist who stated that Debrox was used to loosen up excessive ear wax and the drops were to go in the ear only. She stated that if they were placed in the eye they would be uncomfortable and cause burning, redness, stinging and swelling. She stated that the eye should be immediately flushed out and there would be no permanent effects that she knew of. OSM #7 stated that there was a risk of corneal abrasion because the solution was not filtered for particulates like eye drops were so it should not be placed in anything other than the ear. C) The facility staff failed to administer the medication Baclofen (a muscle relaxant) in a timely manner. A review of R1's clinical record revealed the following physician's orders: 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is important for a resident who is prescribed Baclofen to receive the medication as scheduled because it is for muscle spasms and the resident may present with discomfort if the medication is not administered as scheduled. OSM #7 further stated that if Baclofen is not administered as scheduled and a resident receives doses too close together, the resident may experience an increase in drowsiness, mental confusion and/or a higher risk for falls. The facility policy Medication Administration General Guidelines dated 01/23 documented in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only persons legally authorized to do so . Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart. b. When dose is prepared. c. Before dose is administered . Medications are administered within 60 minutes of schedule time, except before or after meal orders, which are administered based on mealtimes . On 6/5/25 at 2:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the concerns. No further information was presented prior to exit. Reference: (1) Fluorouracil cream and topical solution are used to treat actinic or solar keratoses (scaly or crusted lesions [skin areas] caused by years of too much exposure to sunlight). Fluorouracil cream and topical solution are also used to treat a type of skin cancer called superficial basal cell carcinoma if usual types of treatment cannot be used. Fluorouracil is in a class of medications called antimetabolites. It works by killing fast-growing cells such as the abnormal cells in actinic keratoses and basal cell carcinoma. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a605010.html (2) Debrox (for the ears) is used to soften and loosen ear wax, making it easier to remove . Avoid getting Debrox in your eyes or mouth . This information was obtained from the website: https://www.drugs.com/mtm/debrox-otic.html (3) Baclofen is used to treat pain and certain types of spasticity (muscle stiffness and tightness) from multiple sclerosis, spinal cord injuries, or other spinal cord diseases. Baclofen is in a class of medications called skeletal muscle relaxants. Baclofen acts on the spinal cord nerves and decreases the number and severity of muscle spasms caused by multiple sclerosis or spinal cord conditions. It also relieves pain and improves muscle movement . It usually is taken 3 times a day at evenly spaced intervals. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take baclofen exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682530.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of three units observed, [NAME] unit. The findings include: On 06/04/2025 at t approximately 1:15 p.m. a test tray consisting of pureed fish, pureed broccoli, mashed potatoes, whole broccoli florets, whole fish fillet were placed on a cart and sent to the [NAME] Unit. The cart was followed by this and another surveyor and OSM (other staff member) #2, dietary manager. At approximately 1:26 p.m., the last lunch tray was served to a resident on the [NAME] Unit and OSM #2 was asked to remove the test tray from the cart and proceeded to take the temperatures of the food. The pureed fish was 140° (degrees) F (Fahrenheit), pureed broccoli at 144° F, mashed potatoes 140° F, whole fish fillet at 135° F, and the whole broccoli florets at 135° F. After tasting the food listed above OSM #2 stated that the pureed food did not have any flavor and agreed it was not palatable. When asked about seasoning for the food she stated that they do not add any seasoning to the food. She further stated that the kitchen supplies packets of salt and pepper on the units for residents who want and are allowed salt and/or pepper. When ask if she suppled any type of salt-substitute for resident who cannot have salt she stated no and that if a resident wanted it, it would be supplied by the resident's family. The facility's policy Food and Nutrition Services Staff documented in part, 4. Food will be palatable, attractive, and served in a timely manner at proper temperatures. On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it is determined that the facility staff failed to prepare and serve food in a sanitary manner in one of two facility kitchens. The findings include: On 04/14/2025 an observation of the facility's kitchen revealed the following: On 06/04/2025 at 11:00 a.m. to 1:15 p.m., an observation in the facility's (Name of Facility Kitchen) revealed OSM (other staff member) #3, cook, plating lunch trays for the [NAME], [NAME], and Grace units and the [NAME] dining room. Observations of OSM #3 revealed he had a beard and mustache and had a covering over the beard, but it did not extend over the mustache. Further observation revealed that OSM #3 did not have his mustache covered while plating the lunch trays. On 06/04/2025 at approximately 1:40 p.m. an interview was conducted with OSM #3. When asked to describe the procedure for facial hair when working in the kitchen, he stated that beards and mustaches were to be covered to prevent hair from falling into the food. When informed of the observation described above OSM #3 stated that he was unaware that his mustache was not covered. On 06/04/2025 at approximately 1:05 p.m. an observation in the facility's (Name of Facility Kitchen) kitchen revealed OSM #4 cooking fish filets, raising and lowering the deep fry baskets while wearing gloves. Further observation revealed OSM #4 dumping the cooked fish filets into a four-inch-deep pan and arranging the filets while wearing the same gloves she used to raise and lower the deep fry baskets. On 06/04/2025 at approximately 1:41 p.m. an interview was conducted with OSM #4. When informed of the observation of handling the fish filets for the resident's meal, she stated that she should have not touched the resident's food with her hands. On 06/04/2025 at approximately 11:30 a.m. an observation of the (Name of Facility Kitchen) accessory table next to the steam table revealed a container of chicken salad. OSM # 3, cook, was asked to obtain the temperature of the chicken salad. Using a digital thermometer, he read a temperature of 53 degrees. Further observation revealed immediately after the temperature was obtain, a sandwich was made, placed on a plate, put on a resident's lunch tray and sent out of the kitchen for a resident's lunch. On 06/05/2025 at approximately 4:05 p.m., an interview was conducted with OSM #2, dietary manager. When informed of the observation of OSM #3 not having his mustache covered while plating resident's lunch, she stated that all facial hair, beards and mustaches, should be covered to prevent hair from falling into the resident's food. When informed of the observation of OSM #4 as stated above she stated that OSM #$ should have changed her gloves before handling the resident's food to prevent contamination. When informed of the observation of the chicken salad temperature and being sent to a resident, she stated that the holding temperature should have been 41 degrees or lower and should not have been served. On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for three of 50 residents in the survey sample, Resident #92, Resident #50 and Resident #91. The findings include: 1. For Resident #92, the facility staff failed to maintain the call light in a position where they could access it. Resident #92 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), Parkinson's disease and dementia. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 6/12/24, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 6/17/24 revealed, FOCUS: The resident has an alteration in musculoskeletal status related to fracture right humeral neck. INTERVENTIONS: Anticipate and meet needs. Be sure call light is within reach. On 8/26/24 at 1:30 PM, an observation was made of Resident #92's room. Call bell cord was coiled behind the headboard on the left side of the bed. On 8/27/24 at 8:00 AM, Resident #92 was sitting in the chair by the window on the right side of the bed. The call bell cord was coiled behind the headboard on the left side of the bed. Resident #92 was asked where her call bell was, she stated, they usually come in quite frequently, I do not know where the call bell is. An interview was conducted on 8/27/24 at 8:10 AM with CNA (certified nursing assistant) #1. When asked is she could locate Resident #92's call bell, CNA #1 stated, it is here behind the headboard. When asked if it was accessible to the resident in that location, CNA #1 stated, no, it is not and proceeded to clip the cord to the bedspread. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Answering the Call Light policy revealed in part, be sure the call light is within easy reach of the patient. No further information was provided prior to exit. 2. For Resident #50 (R50), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/23/24, the resident was assessed as being severely impaired for making daily decisions. Section GG documented R50 not having any impairment in the upper extremities and requiring substantial/maximal assistance with toileting and personal hygiene. The resident was assessed as always being incontinent of bowel and bladder. The comprehensive care plan for R50 documented in part, [Name of R50] is at risk for injury due to falls r/t impaired mobility. Date Initiated: 05/11/2022. Revision on: 03/24/2023. Under Interventions it documented in part, Call bell in reach . On 8/27/24 at 7:59 a.m., an observation was made of R50 in their room. R50 was observed lying in bed with the call bell observed on the floor beside the right side of the bed. Additional observations on 8/27/24 at 8:49 a.m., revealed the call bell lying on the floor beside the right side of the bed. On 8/27/24 at 12:13 p.m., R50 was observed lying in bed with the call bell clipped to the pillow located under their head. The press button on the call bell was observed to beside their ear out of R50's reach. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the call bell should be within reach of the resident and normally was hooked near the resident's lap or hooked to the linens so they could reach it. She stated that the resident should always be able to reach it because it was their way to alert the staff if they needed something. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 stated that residents were rounded on every two hours to ensure that the call bell was in reach and to provide care. She stated that the call bell should always be within reach in case the resident needed them for an emergency, had any pain, or anything else they may need. She stated that if the call bell was on the floor the resident would not be able to reach it. On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN (registered nurse) #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was presented prior to exit. 3. For Resident #91(R91), the facility staff failed to assess the resident for the use of grab bars, per the resident request. An interview was conducted with R91 on 8/26/24 at 4:45 p.m. R91 stated she had had sometimes when she has slipped off the side of the bed and would like to have grab bars on one or both sides of the bed to help her with stabilizing herself for standing up. Review of the clinical record failed to evidence a side rail assessment for R91. There was no documented physician order for grab bars. Review of the care plan failed to evidence documentation of grab bars. A request was made for a side rail assessment for R91. On 8/29/24 at 10:47 a.m. ASM (administrative staff member) #2, the director of nursing, stated they do not have a side rail assessment for R91. An interview was conducted with OSM (other staff member) #11, the director of therapy, on 8/29/24 at 2:47 p.m. When asked if a resident can have side rails or grab bars, OSM #11 stated they have to do a grab bar assessment to see if rails would help with the resident's functional abilities. If it is determined that they would help the resident, then the grab bars are put in place. When asked about R91 desire to have grab bars, OSM #11 stated the resident was currently on caseload and was unaware of her desire to have grab bars. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to notify the physician and/or the resident's representative of a change in condition or treatment, for three of 50 residents in the survey sample; Residents #53, #101, and #110. The findings include: 1. For Resident #53, the facility staff failed to evidence that the resident and/or the responsible party was notified of a change in medication on 11/3/23. A review of the clinical record revealed a physician's progress note dated 11/2/23 that documented, Patient seen resting in bed. He reports that his left great toenail has been sore. He would like it examined to make sure there is no acute problem . Cardiovascular: No chest pain, tightness or palpitations Blood Pressure: 100/57 . Heart has a regular rate and rhythm Plan: Recertify. The patient meets criteria for long-term care. Follow blood pressure per facility protocol. Assist with ADLs (activities of daily living) and hygiene as necessary. The patient is at risk for skin breakdown. Monitor the patient to minimize risk . A review of the physician's orders revealed one dated 11/3/23 for Sacubitril-Valsartan (1) Oral Tablet 24-26 MG (milligrams) Give 0.5 tablet by mouth two times a day related to essential hypertension. The above physician's note from the day before did not evidence any discussion and plan to add this medication. Further review of the clinical record failed to evidence any discussion / notification of the addition of this medication by the physician or nursing. On 8/28/24 at 1:00 PM, an interview was conducted with ASM #3 (Administrative Staff Member) an attending physician of the facility, who was not at the facility at the time of this incident. He stated that whenever possible, a medication change should be discussed with the resident and/or the responsible party and should be added to the physician's progress note as part of the plan. On 8/30/24 at 10:45 AM, an interview was conducted with LPN #1 (Licensed Practical Nurse). She stated that notification should have occurred. She stated that the resident has a right to have a say in their treatment plan. The facility policy, Change in a Resident's Condition documented, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status 5. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments .7. The nurse / designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Sacubitril-Valsartan is used to treat heart failure Information obtained from https://medlineplus.gov/druginfo/meds/a615039.html 2. For Resident #101 (R101), the facility staff failed to notify the physician when transportation did not pick the resident up for dialysis and the resident missed her dialysis treatment on 8/24/24. The nurse's notes dated 8/24/24 at 10:49 a.m. documented, Resident was not picked up for dialysis this morning. Attempted to locate contact information for transportation, unable to locate. Called (initials of company) Dialysis spoke to the nurse, and she was also unable to located contact information for transportation, but there also was no more chair time availability for resident. I updated the resident, nursing supervisor and left a vm (voicemail) for the resident's niece. The physician order dated 8/27/24 documented, Dialysis Tues, Thurs, Sat, at (initials of dialysis center) Farmville 6:10 - 9:40 am chair time. Arrive at 5:40 a.m. Dialysis transport provided by (name of company and phone number). On 8/29/24 at 3:43 p.m., ASM (administrative staff member) #9, the regional director of clinical services) stated the nurse who wrote the above note was an agency nurse and wasn't available for interview. A/n interview was conducted with RN (registered nurse) #5, the unit manager, on 8/29/24 at 12:40 p.m. When asked if a resident refuses or misses dialysis for any reason, what should the nurse do, RN #5 stated she would call the provider and responsible party. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 3. For Resident #110, the facility staff failed to notify the responsible party of a fall on 11/2/23. The eINTERACT SBAR (situation, background, assessment, recommendations) dated 11/2/23 at 6:18 a.m. documented in part, The change in condition reported - falls .Primary Care Provider Feedback: New Testing Orders. There was no documentation of the responsible party being notified. Further review of the clinical record failed to evidence documentation that the responsible party was notified after the fall at 6:18 a.m. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked who is notified when a resident falls, RN #5 stated the provider (physician or nurse practitioner) and the responsible party if the resident is not their own responsible party. On 8/30/24 at 10:16 a.m. ASM #2, the director of nursing, reviewed the notes and the care plan for the fall of 11/2/23 and stated there was no notes regarding the notification of the responsible party at the time of the fall. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations and ASM #9, the regional director of clinical services, were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to issue a beneficiary notice of non-coverage in a timely manner for one of three beneficiary notice reviews, Resident #257. The findings include: For Resident #257 (R257), the facility staff failed to provide an advance beneficiary notice of non-coverage in a timely manner. A review of a list of residents discharged from a Medicare covered Part A stay with benefit days remaining revealed R257 was discharged from services on 5/22/24. A Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented, Medicare doesn't pay for everything, even some care that you or your health care provider think you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on 5/23/24, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs . The notice was signed by OSM (other staff member) #4 (the discharge planner) on 5/14/24 and signed by R257 on 5/22/24. On 8/27/24 at 8:29 a.m., an interview was conducted with OSM #4. OSM #4 stated she spoke with R257 regarding the beneficiary notice on 5/14/24 but did not obtain the resident's signature until 5/22/24. When asked why she did not obtain R257's signature when she spoke with the resident on 5/14/24, OSM #4 stated she thought she may have left the papers in the resident's room, and she was not sure. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Advanced Beneficiary Notice (ABN) documented, 7. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided within forty-eight hours of the last anticipated covered day. No further information was presented prior to exit.

Based on staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 50 residents in the survey sample, Resident # 115. The findings include: The MDS assessment, an admission assessment with an assessment reference date of 5/7/23, in Section B - Hearing, Speech and Vision, coded the resident as usually being understood and usually understands. In Section C - Cognitive Patterns, there were dashed documented in the section for the resident interview and the section for staff interview. Under C0100 - Should Brief Interview for Mental Status Be Conducted, a dash was documented. An interview was conducted with RN (registered nurse) #6, the MDS coordinator, on 8/29/24 at 9:29 a.m. When asked who does Section C, RN #6 stated sometimes she does it but normally it's the social worker that does it. RN #6 was no employed at the facility at the time of the assessment above. The above assessment was reviewed with RN #6. RN #6 stated there shouldn't be dashes, the staff interview should have been done if the resident couldn't do the interview, but the resident was coded as being usually understood and usually understands, it should have been completed. When asked what reference the facility uses to complete the MDS assessments, RN #6 stated, the RAI (Resident Assessment Instrument) manual. The Facility RAI Manual, Version 1.18.11 - October 2023 documented in part, If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items. Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan for two of 50 residents in the survey sample, Resident #113 and Resident #407. The findings include: 1. The facility failed to develop a baseline care plan to include monitoring of anticoagulation therapy for Resident #113. Resident #113 was admitted to the facility on [DATE] with diagnosis that included fractures and hypertension. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and independent for eating. A review of the baseline care plan dated 8/3/23 revealed, FOCUS: Resident has actual impairment to skin integrity related to Surgical Wound. INTERVENTIONS: Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. A review of the physician order dates 7/21/23 revealed Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML. Inject 0.4 ml subcutaneously every 12 hours. There is no evidence of the baseline care plan including any focus or interventions related to anticoagulation therapy or monitoring. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked what the baseline care plan should include, LPN #2 stated, it should include the initial plan of care for the resident. When asked if a resident is ordered anticoagulation therapy, should it be included on the baseline care plan, LPN #2 stated, yes, it should be included. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Baseline Care Plan policy revealed in part, will implement a baseline care plan to meet the resident's immediate care needs based on orders, services, medications and treatments. No further information was provided prior to exit. 2. The facility failed to develop a baseline care plan to include monitoring of CPAP therapy for Resident #407. Resident #407 was admitted to the facility on [DATE] with diagnosis that included fracture right lower leg, OSA (obstructive sleep apnea), asthma and paroxysmal atrial fibrillation. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 8/16/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being max assist for mobility/transfers, dressing, hygiene toileting and independent for eating. Section O-Special Treatments and Procedures coded the resident as non-invasive Bipap-yes. A review of the baseline care plan dated 8/23/24 revealed, FOCUS: Resident has actual impairment to skin integrity related to Surgical Wound. INTERVENTIONS: Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. There is no evidence of the baseline care plan including any focus or interventions related to CPAP (continuous positive airway pressure) use or monitoring. A review of the physician order dates 8/13/24 revealed CPAP on at HS at bedtime Per home settings. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked what the baseline care plan should include, LPN #2 stated, it should include the initial plan of care for the resident. When asked if a resident is ordered CPAP therapy, should it be included on the baseline care plan, LPN #2 stated, yes, it should be included. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Baseline Care Plan policy revealed in part, will implement a baseline care plan to meet the resident's immediate care needs based on orders, services, medications and treatments. No further information was provided prior to exit.

Based on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for three of 50 residents in the survey sample, Residents #11, #114 and #110. The findings include: 1. For Resident #11 (R11), the facility staff failed to revise the comprehensive care plan to include the use of grab bars. On the most recent MDS (minimum data set) assessment, a significant change assessment with an ARD (assessment reference date) of 7/12/24, the resident scored 10 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. On 8/26/24 at 3:00 p.m., an interview was conducted with R11 in their room. R11 was observed in bed with bilateral grab bars on each side of the upper portion of the bed. R11 stated that the bars assisted them to turn and position themselves in the bed. The physician orders for R11 documented in part, Bilateral grab bars applied to the bed. Order Date: 06/13/2024. The side rail & entrapment risk assessment for R11 dated 6/12/24 documented the resident able to safely use both upper grab bars for independent bed mobility. The comprehensive care plan for R11 failed to evidence the use of the grab bars for independent bed mobility. The ADL (activities of daily living) care plan documented, [Name of R11] has an ADL self-care performance deficit r/t muscle weakness, difficulty walking, wound to buttocks. Date Initiated: 02/23/2024. Revision on: 06/19/2024. Under Interventions it documented in part, Bed Mobility: The resident requires assistance by staff. Date Initiated: 07/16/2024 . On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to show the staff what they were supposed to do for the resident. She stated that it was their treatment plan, and it was revised and reviewed by both nursing staff and the MDS staff in the care plan meetings. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that the care plan purpose was for the staff to have a complete person-centered plan that showed what needed to be done for the resident. She stated that the care plan was updated after clinical meetings and done by the interdisciplinary team. She stated that normally bed rails were on the care plan because they required an assessment and an order and if not properly documented they could be considered a restraint. She stated that the MDS team normally added them to the care plan. The facility policy, Care Planning- Comprehensive Person-Centered documented in part, .Each resident's comprehensive care plan will describe the following: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: .d. When the goals, needs, and preferences change .f. At least quarterly and after each OBRA MDS assessment . On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was obtained prior to exit. 2. For Resident #114 (R114), the facility staff failed to revise the comprehensive care plan to include treatment for a non-pressure related skin condition. The physician orders for R114 documented in part, - Nystatin External Cream 100000 UNIT/GM (Nystatin (Topical)) Apply to affected areas topically every day and evening shift for redness until healed. Order Date: 06/13/2024. Review of the eTAR (electronic treatment administration record) for R114 dated 8/1/23-8/31/23 failed to evidence the Nystatin treatment completed on day shift on 8/2/23-8/7/23, 8/12/23-8/14/23, 8/19/23-8/21/23, 8/26/23-8/28/23 and 8/31/23. It further failed to evidence the Nystatin treatment completed on evening shift on 8/1/23-8/2/23, 8/5/23-8/6/23, 8/12/23-8/13/23, 8/19/23, 8/27/23 and 8/31/23. Review of the eTAR for R114 dated 9/1/23-9/30/23 failed to evidence the Nystatin treatment completed on day shift on 9/1/23-9/2/23, 9/4/23, 9/9/23, 9/11/23-9/12/23, 9/16/23-9/18/23, and 9/18/23. It further failed to evidence the Nystatin treatment completed on evening shift on 9/1/23-9/2/23, 9/9/23, 9/16/23-9/18/23, 9/21/23, and 9/23/23. Review of the eTAR for R114 dated 10/1/23-10/31/23 failed to evidence the Nystatin treatment completed on day shift on 10/7/23 and 10/20/23. The comprehensive care plan for R114 documented in part, [Name of R114] has potential for impairment of skin integrity r/t bowel and bladder incontinence. Date Initiated: 05/10/2022. Revision on: 03/13/2024. It failed to evidence the skin redness requiring the use of Nystatin from 7/3/23-7/24/23, 7/28/23-10/20/23 and 11/13/23-12/27/23. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to show the staff what they were supposed to do for the resident. She stated that it was their treatment plan, and it was revised and reviewed by both nursing staff and the MDS staff in the care plan meetings. LPN #1 stated that treatments were evidenced as completed by the staff signing them off on the eTAR. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that the care plan purpose was for the staff to have a complete person-centered plan that showed what needed to be done for the resident. She stated that the care plan was updated after clinical meetings and done by the interdisciplinary team. She stated that the nursing staff provided care to any yeast rashes and evidenced the treatment as done by signing it off on the eTAR. On 8/30/24 at approximately 11:39 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #9, the regional director of clinical operations, and ASM #8, the regional director of operations were made aware of the concern. No further information was obtained prior to exit. 3. For Resident #110 (R110), the facility staff failed to review and revise the comprehensive are plan after the resident had a fall on 11/2/23. The eINTERACT SBAR (situation, background, assessment, recommendations) dated 11/2/23 at 6:18 a.m. documented in part, The change in condition reported - falls .Primary Care Provider Feedback: New Testing Orders. There was no documentation of the responsible party being notified. The comprehensive care plan dated, 8/4/23, documented in part, Focus: (R110) had an actual fall. The Interventions documented, Lab (laboratory) work as needed. OT (occupational therapy) order placed. X-ray ordered by MD/NP (medical doctor/nurse practitioner). The care plan further documented, dated 5/11/22, Focus: (R110) is at risk for falls. The Interventions documented in part, 10/4/22 - Encourage toileting q (every) 2-3 hours. 10/4/22 - Ensure wheelchair within reach. 10/4/22 - nurse to therapy referral prn (as needed). 8/8/23 - OT consult for treatment and evaluation. 5/11/22 - Provide assist with transfers, ambulation and bed mobility as necessary. 5/11/22 - Call bell within reach. 5/11/22 - Monitor/document/report PRN x 72 h (hours) to MD for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. 5/11/22 - neuro-checks as ordered. 5/11/22 - PT (physical therapy) consult for strength and mobility. There was no documented review or revision to the care plan after the fall of 11/2/23. An interview was conducted with RN (registered nurse) #5, the unit manager, on 8/29/24 at 12:40 p.m. When asked who is responsible for updating the care plan after a resident falls, RN #5 stated, the interdisciplinary team comes up with a plan and then it's updated by the MDS (minimum data set) nurse at the clinical meeting. The care plan for R110 was reviewed with ASM (administrative staff member) #2, the director of nursing, on 8/30/24 at 10:16 a.m. ASM #2 stated she did not see any updating of the care plan after the fall of 11/2/23. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations and ASM #9, the regional director of clinical services, were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was provided prior to exit.

3. For Resident #72 (R72), the facility staff failed to clarify two prn (as needed) orders for pain medication. A review of R72's clinical record revealed the following orders: 7/23/24 Oxycodone (an opioid pain medication) Oral Tablet 10 mg (milligrams) .Give 2 tablets by mouth every 4 hours as needed for pain. 7/16/24 Oxycodone-Acetaminophen (Percocet, an opioid pain medication) 7.5 - 325 mg Give 1 tablet by mouth every 4 hours as needed for pain medication. A review of R72's August 2024 MAR (medication administration record) revealed he received a total of 21 as needed doses of Oxycodone between 8/1/24 and 8/28/24. R72 received 28 doses of Percocet between 8/1/24 and 8/28/24. The review revealed pain level assessments prior to the administration of these pain medications to range primarily between 7 and 10. The as needed medications were administered over the entire range of days, evenings, and nights. The review revealed no clarification for these orders as to under which circumstances or pain rating each medication should be given. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) # 5, a unit manager, was interviewed. She stated if a resident has two orders for prn pain medication, each order should specify the circumstances under which each medication should be given. After reviewing R72's August 2024 MAR, she stated: I'm not sure how the nurses know which medication to give (Percocet or Oxycodone). It should have a pain scale. It looks like his pain levels are the same for each [prn medication]. There should have been a parameter. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for three of 50 residents in the survey sample, Residents #157, #34 and #72. The findings include: 1. For Resident #157, the facility staff failed to clarify two physician orders for blood sugar checks with insulin coverage in the clinical record at the same time. The physician order dated 8/9/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals and at bedtime for diabetes. D/C (discontinue date) 8/18/24. This order was documented on the MAR (medication administration record) from 8/9/24 through 8/18/24. The physician order dated 8/12/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals for diabetes. This order was documented on the MAR from 8/12/24 through 8/23/24. On the following dates and times, the nurses documented, Duplicate order. 8/13/24 at 6:41 p.m. 8/14/24 at 7:09 a.m. 8/14/24 at 4:14 p.m. 8/15/24 at 6:08 a.m. 8/16/24 at 8:30 a.m. 8/16/24 at 12:03 p.m. 8/16/24 at 5:15 p.m. 8/17/24 at 6:43 a.m. 8/17/24 at 11:00 a.m. 8/17/24 at 4:47 p.m. 8/18/24 at 6:17 a.m. 8/18/24 at 12:30 p.m. An interview was conducted with RN (registered nurse) #5 on 8/29/24 at 12:40 p.m. When asked if she, as a nurse, saw a duplicate order on the MAR for a resident, what would she do, RN #5 stated, she would discontinue the duplicate order. RN #5 was asked if she would just document duplicate order at the time of administration, RN #5 stated, she would talk to the provider to make sure which of the orders is the correct one. The facility policy, Medication Administration, did not address when there are duplicate orders on the MAR. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 2. For Resident #34 (R34), the facility staff failed to administer medications per the physician orders for Metformin (used to treat diabetes) and Seroquel (used to treat schizophrenia). During an interview with R34 on 8/26/24 at 3:45 p.m. R34 stated that on 7/12/24 she did not get her medications until after 10:00 p.m. The physician order dated, 8/24/23, documented, Seroquel Oral Tablet 100 mg (milligrams); give 1.5 tablet by mouth at bedtime related to schizophrenia. The Seroquel is scheduled for administration at 9:00 p.m. Metformin HCL (hydrochloride) Oral Tablet 500 MG; give 1 tablet by mouth two times a day for diabetes. Give before meals. The scheduled time was 6:00 p.m. Dinner is served at the facility at 5:00 p.m. The MAR (medication administration record) for July 2024 documented the above orders. On 7/12/24 the Seroquel was documented as having been administered at 10:43 p.m., 1 hour and 45 minutes after the scheduled time. The Metformin was documented as having been administered on 7/12/24 at 7:58 p.m., 1 hour and 58 minutes after the scheduled time, which is still after the meal is served. An interview was conducted with RN #5, the unit manager, on 8/29/24 at 12:40 p.m. When asked when medications are to be administered, RN #5 stated, one hour before or one hour after the scheduled time. The facility policy, Medication Administration documented in part, The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed at the following stages during medication administration. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for an indwelling catheter for two of 50 residents in the survey sample, Residents #67 and #24. The findings include: 1. For Resident #67 (R67), the facility staff failed to provide urinary catheter care on multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, the resident scored seven out of 15 on the BIMS (brief assessment for mental status), indicating R67 was severely impaired for making daily decisions. Section H documented R67 having an indwelling urinary catheter. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under hospice care. R67's family member stated that they had multiple concerns regarding the care that was received at the facility. R67's family member stated that the staff emptied the catheter bag but were not sure about what care they provided for the catheter itself. The comprehensive care plan for R67 documented in part, [Name of R67] has a 16Fr foley catheter r/t BPH (benign prostatic hypertrophy), obstructive uropathy. Date Initiated: 12/04/2023. Revision on: 08/26/2024. Under Interventions it documented in part, Catheter care q (every) shift and as needed. Date Initiated: 04/03/2024 . The physician orders for R67 documented in part, Cath care every shift and as needed every shift. Order Date: 12/04/2023. Review of the eTAR (electronic treatment administration record) for R67 dated 6/1/24-6/30/24 failed to evidence catheter care provided on day shift on 6/7/24, and on evening shift 6/7/24 and 6/24/24. Review of the eTAR for R67 dated 7/1/24-7/31/24 failed to evidence catheter care provided on day shift on 7/3/24. Review of the eTAR for R67 dated 8/1/24-8/30/24 failed to evidence catheter care provided on day shift on 8/12/24 and 8/17/24, on evening shift on 8/13/24 and 8/15/24 and on night shift 8/9/24 and 8/24/24. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 stated that catheter care was provided every shift. She stated that they emptied the catheter bags and cleaned the skin around the catheter unless there was a special treatment ordered and then the nurse did the treatment. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that the catheter care was provided as ordered by the physician. She stated that the orders triggered on the eTAR for the nurse to complete the treatment and document it as completed. She stated that the documentation was how the care was evidenced as completed. She stated that if there were no orders for the catheter the physician should be called to get orders for care. The facility policy Urinary Catheter Care documented in part, .Documentation- The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given . On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. 2. For Resident #24 (R24), the facility staff failed to provide catheter care on multiple dates from 6/1/24 through 7/30/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/14/24, the resident scored 15 out of 15 on the BIMS (brief assessment for mental status), indicating R24 was cognitively intact for making daily decisions. Section H documented R24 having an indwelling catheter. On 8/26/24 at 2:18 p.m., an interview was conducted with R24 in their room. A urinary catheter bag was observed attached to the bed frame of R24's bed with a privacy cover intact. R24 stated that they had a urinary catheter and had it for a few years now which they saw the urologist for regularly. R24 stated that the staff changed the catheter when it was leaking and emptied the bag every day. R24 stated that the staff kept gauze around the catheter site and changed it when it came off. R24 stated that they were unsure if there was a schedule for catheter care of not. The comprehensive care plan for R24 documented in part, [Name of R24] has Suprapubic (1) Catheter: Obstructive Uropathy. Date Initiated: 07/29/2022. Revision on: 09/07/2022. Under Interventions it documented in part, .Catheter care Q (every) shift and PRN (as needed). Date Initiated: 07/29/2022 . The physician orders for R24 documented in part, - Order Date: 06/06/2022. Cath care every shift and as needed- may be performed by CNA (certified nursing assistant), verified by nurse every shift. End Date: 06/06/2024. - Order Date: 08/02/2024. Foley cath care every shift and prn (as needed). every shift related to Neuromuscular dysfunction of bladder, unspecified. - Order Date: 06/26/2024. regular gauze cut with split to place around suprapubic catheter, Zinc oxide to periwound daily and PRN for soilage and or dislodgement. as needed for soilage and or dislodgement AND every day shift. Review of the eTAR (electronic treatment administration record) for R24 dated 6/1/24-6/30/24 failed to evidence catheter care provided 6/4/24-6/26/24. Review of the eTAR for R24 dated 7/1/24-7/31/24 failed to evidence catheter care provided on 7/26/24 and 7/29/24. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 stated that catheter care was provided every shift. She stated that they emptied the catheter bags and cleaned the skin around the catheter unless there was a special treatment ordered and then the nurse did the treatment. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that catheter care was provided as ordered by the physician. She stated that the orders triggered on the eTAR for the nurse to complete the treatment and document it as completed. She stated that the documentation was how the care was evidenced as completed. She stated that if there were no orders for the catheter the physician should be called to get orders for care. On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made a catheter necessary, or another health problem. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000145.htm.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to complete nutritional assessments and obtain daily weights for one of 50 residents in the survey sample, Resident #34. The findings include: A. For Resident #34 (R34), the facility failed to obtain physician ordered daily weights. An interview was conducted with R34 on 8/26/24 at 3:45 p.m. R34 stated that she is supposed to have daily weights done. She stated if she didn't go to the scales to get weighed, no one would come get her to do it. She has missed a few weights. The physician order dated, 7/12/24, documented, Daily weights every day shift for sig (significant) weight gain. Use same scale/method for each wt (weight). The MAR (medication administration record) for July 2024 and August 2024 documented the above order. On 7/13/24, 7/14/24 and 7/20/24, there were blanks where the weight was to be documented. The comprehensive care plan dated 8/17/23 and revised on 8/9/24, documented in part, Focus: (R34) is at risk for alteration in nutritional status risk for malnutrition, multiple comorbidities. Regular diet. Res. (resident) has potential for weight gain r/t (related to) enjoying snacks and additional sandwiches with meals. The Interventions documented in part, Daily Weight r/t sig (significant) weight gain. An interview was conducted with RN (registered nurse) #5, the unit manager, on 8/29/24 at 12:40 p.m. When asked how she evidenced the physician ordered daily weights, RN #5 stated, it's documented in the electronic record. The facility policy, Physician Orders did not evidence following the physician orders. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations, and ASM #9, the regional director of clinical services, were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was obtained prior to exit. B. For Resident #34, the facility staff failed to complete a quarterly nutritional assessment. There was no assessment between 12/6/23 and 5/1/24. The review of the clinical chart revealed a nutritional assessment and note dated, 12/6/23. The nutritional note documented in part, Weight review: Resident 73 yo (year old) F (female) now reporting a sign (significant) wt (weight) gain x 3,6 mos. (months). Wt not taken x 2 mos .no change made at this time. Honor food preferences. Monitor nutrition parameters. Continue POC (plan of care). The next nutritional assessment was dated, 5/1/24. The assessment documented in part, Plan of Care: Problem Statement: no nutritional concern at this time. Goal: maintain weight through next review date. Interventions/Approaches: Recommend re-weigh to confirm weight change. The Nutritional Note dated, 5/29/24, documented in part, 73 yo F seen for sig (significant) wt gain .Undesirable sig wt gain x 1 mo (month) (12%) from 4/2 wt; r/t multiple psych (psychiatric) medications that may cause app (appetite) stimulation/wt gain .Recommend: Begin weekly weights to monitor wt changes to establish new baseline wt for confirmation of wt change. Recommend using same scale/method of weighing for most accurate wt. Monitor for fluid shift/edema to confirm not fluid retention, continue preventative measures. A request was made for a nutritional assessment between 12/6/23 and 5/1/23. On 8/28/24 at 3:46 p.m. ASM (administrative staff member) #9 stated the resident should have had a nutritional quarterly assessment in March, but it was not completed. An interview was conducted with OSM (other staff member) #12, the current dietician, on 8/29/24 at 2:22 p.m. When asked how often nutritional assessments are to be completed, OSM #12 stated, quarterly, annually on admission and readmission, and if the resident is at high risk, then monthly. Reviewed the above assessments and nutritional notes with OSM #12. OSM #12 was asked if the resident triggered for a weight gain in December of 2023, wouldn't they have an assessment the next month, OSM #12 stated, if the resident triggered again the next month, then, yes, an assessment should have been completed but if the resident didn't trigger in the next month, then their next assessment would be at their next scheduled assessment, either a quarterly or annual assessment. The facility policy, Nutritional Assessment documented in part, POLICY:As part of the comprehensive assessment, a nutritional evaluation, including current nutritional status, risk factors, for impaired nutrition, and resident preferences shall be conducted for each resident. 1. The dietitian, in conjunction with dietary staff, nursing staff, and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3.The dietitian/designee will complete the facility approved nutritional assessment tool. Analysis of the collected nutritional data will include: a. An estimate of calorie, protein, nutrient, and fluid needs; b. Whether the resident's current intake is adequate to meet his or her nutritional needs; and c. Special food formulations. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations, and ASM #9, the regional director of clinical services, were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to perform safety assessments for the use of side rails for one of 50 residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93), the facility staff failed to assess the resident for safe side rail usage. On 8/27/24 at 9:02 a.m., R93 was observed sitting up in bed eating breakfast. Both quarter side rails were up on his bed. A review of R93's clinical record, including assessments, physician orders, and care plan, revealed no evidence of an assessment for R93's need for the use of side rails and for R93's ability to use the side rails safely. On 8/28/24 at 8:41 a.m., ASM (administrative staff member) #2, the director of nursing, stated she could not locate any evidence of a safety assessment for R93's use of side rails. On 8/29/24 at 12:40 p.m., RN (registered nurse) #5, a unit manager, was interviewed. She stated before a resident's bed is equipped with side rails of any kind, PT (physical therapy) and OT (occupational therapy) must perform an assessment for the resident's ability to use the side rails safely, and for the resident's need for the side rails. Once those assessments are completed, it is the responsibility of PT or OT to put the orders in the system. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide physician oversight for the care of four of 50 residents in the survey sample, Residents #96, #72, #112, and #117. The findings include: 1. For Resident #96 (R96), the facility physician and/or nurse practitioner (NP) failed to assess the resident's prn (as needed) pain medication usage. For Resident #96 (R96), the facility staff failed to assess the resident's need for an increase in his scheduled pain medication. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated he was concerned about having to ask so frequently for pain medications. He stated sometimes the staff was too busy to bring the medications in a timely manner, and he did not feel he should have to ask for pain medication so many times during the day and night. A review of R96's clinical record revealed the following orders: 7/31/24 Oxycodone (an opioid pain medication) Oral Tablet 10 mg (milligrams) .Give 2 tablets by mouth every 4 hours as needed for breakthrough pain related to multiple sclerosis. 8/15/24 Oxycodone Oral Tablet 10 mg .Give 2 tablets every 4 hours as needed for breakthrough pain. A review of R96's August 2024 MAR (medication administration record) revealed he received a total of 51 as needed doses of Oxycodone between 8/1/24 and 8/28/24. The review revealed pain level assessments prior to the administration of the Oxycodone to range between 6 and 9. The as needed Oxycodone was administered over the entire range of days, evenings, and nights. On 8/28/24 at 12:38 p.m., ASM (administrative staff member) #4, the attending physician, was interviewed. When asked his role in monitoring prn (as needed) pain medication for residents, he stated a resident's frequent usage of a prn pain medication could be mentioned either by the resident or by the nurse. He stated: Certainly if the prns are being given around the clock, or the resident is frequently requesting a dose, something needs to be adjusted. He stated the resident's maintenance (scheduled) pain medication may need to be increased. He added this decision should take into account the reason for the pain, with the goal of getting the resident off of narcotic pain medications as soon as possible. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated when the nursing staff notices a trend of the resident being in constant pain, the nurses talk to the nurse practitioner to see if something needs to be scheduled or increased. She added: It is situational. We look for the need and address it. She stated the responsibility for this belongs both to the nurses and to the providers (nurse practitioners and physicians). After reviewing R96's August 2024 MAR, she stated when the prn medications are being used as frequently as R96 was using them, the nurse practitioner or physician should have made an adjustment. On 8/29/24 at 9:40 a.m., ASM #4, the nurse practitioner, was interviewed. She stated she has just started getting to know the residents at this facility. She stated: I'm seeing a lot of people just on prn medications for pain. She stated if residents are requesting frequent prn pain medication, she would try to schedule a one-time nighttime dose. She added: I try to get them on a once or twice a day schedule, and move them to Tylenol instead of the opioids. After reviewing R96's August 2024 MAR, she stated: I would put him on an extended release opioid twice a day, and schedule it. He shouldn't have to ask for that much medication so frequently. She stated the responsibility for reviewing a resident's as needed medication usage falls to both the nurses and the providers. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. A review of the facility policy, Attending Physician Responsibilities, revealed, in part: The Attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility .Each Attending Physician will be responsible for .Accepting responsibility for initial and subsequent resident care .Providing appropriate resident care .Providing appropriate, timely medical orders .The Attending Physician will assess new admissions in a timely fashion .The Attending Physician NPP will seek, provide, and analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with regulations and care standards. No further information was provided prior to exit. 2. For Resident #72 (R72), the facility physician and/or nurse practitioner (NP) failed to assess the resident's prn (as needed) pain medication usage. A review of R72's clinical record revealed the following orders: 7/23/24 Oxycodone (an opioid pain medication) Oral Tablet 10 mg (milligrams) .Give 2 tablets by mouth every 4 hours as needed for pain. 7/16/24 Oxycodone-Acetaminophen (Percocet, an opioid pain medication) 7.5 - 325 mg Give 1 tablet by mouth every 4 hours as needed for pain medication. A review of R72's August 2024 MAR (medication administration record) revealed he received a total of 49 as needed doses of Oxycodone or Percocet between 8/1/24 and 8/28/24. The review revealed pain level assessments prior to the administration of the pain medications to range primarily between 7 and 10. The as needed medications were administered over the entire range of days, evenings, and nights. On 8/28/24 at 12:38 p.m., ASM (administrative staff member) #4, the attending physician, was interviewed. When asked his role in monitoring prn (as needed) pain medication for residents, he stated a resident's frequent usage of a prn pain medication could be mentioned either by the resident or by the nurse. He stated: Certainly if the prns are being given around the clock, or the resident is frequently requesting a dose, something needs to be adjusted. He stated the resident's maintenance (scheduled) pain medication may need to be increased. He added this decision should take into account the reason for the pain, with the goal of getting the resident off of narcotic pain medications as soon as possible. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated when the nursing staff notices a trend of the resident being in constant pain, the nurses talk to the nurse practitioner to see if something needs to be scheduled or increased. She added: It is situational. We look for the need and address it. She stated the responsibility for this belongs both to the nurses and to the providers (nurse practitioners and physicians). After reviewing R72's August 2024 MAR, she stated when the prn medications are being used as frequently as R72 was using them, the nurse practitioner or physician should have made an adjustment. On 8/29/24 at 9:40 a.m., ASM #4, the nurse practitioner, was interviewed. She stated she has just started getting to know the residents at this facility. She stated: I'm seeing a lot of people just on prn medications for pain. She stated if residents are requesting frequent prn pain medication, she would try to schedule a one-time nighttime dose. She added: I try to get them on a once or twice a day schedule, and move them to Tylenol instead of the opioids. After reviewing R72's August 2024 MAR, she stated: I would put him on an extended release opioid twice a day, and schedule it. He shouldn't have to ask for that much medication so frequently. She stated the responsibility for reviewing a resident's as needed medication usage falls to both the nurses and the providers. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 3. For Resident #112 (R112), the facility physician and/or nurse practitioner (NP) failed to identify the resident's need for blood sugar checks and insulin upon admission. A review of R112's hospital Discharge summary dated [DATE] revealed, in part: Discharge Diagnoses .Diabetes mellitus type 2 .continue current regimen .Medications Inpatient .Insulin lispro .with meals and at bedtime. A review of R112's clinical record revealed he was admitted to the facility on [DATE]. This review revealed the following progress notes: 8/26/23 at 7:00 p.m. Resident's spouse voiced concerns he didn't have accucheck (test for blood glucose levels) orders nor insulin orders, and that he was [name of medication to treat diabetes] at home .at hospital .he was on insulin. MD (medical doctor) on call made aware and insulin orders given. A review of R112's MAR (medication administration record) revealed he received a one-time dose of Humalog Lispro (short-acting insulin) 15 units on 8/26/23 at 7:00 p.m. This review failed to reveal any blood sugar checks or insulin administration between his admission on [DATE] at 8:00 p.m. and 8/27/23 at 7:00 p.m. On 8/29/24 at 9:40 a.m., ASM (administrative staff member) #4, a nurse practitioner, was interviewed. She stated if a resident has been on accuchecks and insulin in the hospital, she would initially order sliding scale insulin before meals and at bedtime. Once the resident's insulin needs have been established, she stated she attempts to get the resident on scheduled insulin rather than a sliding scale. She added: If they are on something at the hospital, they should be on something here. She stated the responsibility for reviewing a resident's admission medications falls to both the nurses and the providers. On 8/29/24 at 1:07 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated if a resident is discharged with orders for insulin, those orders should be called in to the provider for approval. She stated the whole of the resident's discharge records should be reviewed for accurate medication reconciliation. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 4. For Resident #117 (R117), the facility physician and/or nurse practitioner (NP) failed to identify the resident's need for blood sugar checks and insulin upon admission. A review of R117's hospital Discharge summary dated [DATE] revealed, in part: Primary Discharge Diagnosis .Diabetes mellitus .Diabetes mellitus with hyperglycemia (high blood sugar) .Continue glycemic protocol .Consider increasing sliding scale. A review of R117's clinical record revealed the resident was admitted to the facility on [DATE] at approximately 10:00 p.m. This review revealed the following progress notes: 1/28/23 Note text 1903 (7:03 p.m.) .Notified by RP (responsible party) resident is on scheduled insulin and accuchecks (blood sugar checks) four times a day at home. NP (nurse practitioner) made aware and new orders received and RP made aware. This reviewed revealed the provider gave orders for accuchecks and insulin on 1/28/23 at 7:26 p.m. These were the first orders for accuchecks and insulin since the resident's admission on [DATE]. On 8/29/24 at 9:40 a.m., ASM (administrative staff member) #4, a nurse practitioner, was interviewed. She stated if a resident has been on accuchecks and insulin in the hospital, she would initially order sliding scale insulin before meals and at bedtime. Once the resident's insulin needs have been established, she stated she attempts to get the resident on scheduled insulin rather than a sliding scale. She added: If they are on something at the hospital, they should be on something here. She stated the responsibility for reviewing a resident's admission medications falls to both the nurses and the providers. On 8/29/24 at 1:07 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated if a resident is discharged with orders for insulin, those orders should be called in to the provider for approval. She stated the whole of the resident's discharge records should be reviewed for accurate medication reconciliation. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide a physician ordered medication for administration to two of 50 residents in the survey sample, Residents #96 and #34. The findings include: 1. For Resident #96 (R96), the facility staff failed to provide Avonex (a medication to treat multiple sclerosis) for timely administration. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated he was concerned about not receiving a weekly injection to treat his multiple sclerosis weekly on Saturdays. He stated he thought it was important that this medication be given on time, every seven days. A review of R96's clinical record revealed the following physician order dated 7/13/24: Avonex Prefilled Intramuscular Prefilled Syringe Kit 30 mcg/0.5 ml (micrograms per milliliter). Inject 1 syringe intramuscularly one time a day every Sat (Saturday) related to multiple sclerosis. Family to bring from home. A review of R96's progress notes revealed, in part: 8/3/24 [Avonex] not given. Not available. Waiting on family. 8/10/24 [Avonex] not given .waiting on the family to bring in. 8/10/24 [Avonex] not given .waiting on family. A review of R96's August 2024 MAR (medication administration record revealed that R96 did not receive the medication on any of the three Saturdays in August prior to survey entrance. Instead of Saturday, 8/3/24, the resident received the medication on Tuesday, 8/6/24. The resident then received the medication on subsequent Tuesdays 8/13 24 and 8/20/24. This review R96 did not receive Avonex between 7/27/24 and 8/6/24, a total of 10 days between administrations. The clinical record review revealed no evidence of efforts by the facility to communicate with the pharmacy or the family regarding the resident's Avonex availability. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. When asked about R96's Avonex injections, she stated: The wife brings it in. There has been an issue with the wife bringing the medication on the day it needs to be given. I know that on one Saturday, it wasn't given because it wasn't here to be given. She stated she is aware the medication is very expensive, and she did not know what to do if the wife did not bring the medication to the facility for the nurses to administer to R96. On 8/29/24 at 11:06 a.m., ASM (administrative staff member) #5, the registered pharmacist, was interviewed. He stated he was not familiar with R96's Avonex, and encouraged conversation with OSM (other staff member) #9, a pharmacy technician at the facility's contract pharmacy. He stated he believed the electronic medical record contained information that the family would provide the medication, adding that the facility would be very expensive for the facility to provide. He added: We did not provide it. That's a facility decision. If the facility tells us the family is going to provide a medication, we say it's okay. On 8/29/24 at 11:35 a.m., OSM #9 was interviewed. She stated the facility gave the pharmacy directions not to fill the physician order for Avonex for R96. She stated: The family was bringing it from home. This is not unusual for the facility. OSM #9 stated she would check with a pharmacist about the directions to be followed if a resident missed a dose. At 11:53 a.m., OSM #9 called the survey team and said the manufacturer's instructions for Avonex say to give the dose as soon as possible, then to get back on the original schedule. According to the manufacturer's instructions, the duration of the medication is only four days, so it needs to be administered regularly. A review of directions for administration of Avonex revealed, in part: If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses .Avonex®: If you miss a dose, give it as soon as you can. Go back to your regular schedule the following week. Do not use this medicine 2 days in a row. This information is taken from the website https://www.mayoclinic.org/drugs-supplements/interferon-beta-1a-intramuscular-route-subcutaneous-route/proper-use/drg-20064352 On 8/29/24 at 3:20 p.m., ASM #2, the director of nursing, was interviewed. She stated: The Avonex was priced out. It is a high cost medication. She stated she was aware R96 was on the medication at home, but was not sure what the communication was between the facility staff and the family regarding when the medication would be brought to the facility, and who would bring it. She stated: I don't know if this is an insurance thing. When asked who was responsible for obtaining medications and giving the medications in a timely manner, she stated: We are. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the A review of the facility policy, Unavailable Medications, revealed, in part: The facility must make every effort to ensure that medications are available to meet the needs of each resident .The nursing staff shall .notify the attending physician .of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. No further information was provided prior to exit. 2. For Resident #34(R34), the facility staff failed to ensure Meclizine was available for administration. An interview was conducted with R34 on 8/26/24 at 3:45 p.m. R34 stated that the facility runs out of medications all the time, so she misses doses. The physician order dated, 7/2/24, documented, Meclizine HCL (hydrochloride) 12.5 MG (milligrams); Give 1 tablet by mouth three times a day for vertigo. The July 2024 MAR (medication administration record) documented the above order. On 7/2/24 at the 5:00 p.m. dose, a 5 was documented. A 5 indicates Hold/See Progress Note. The progress note dated 7/2/24 at 6:04 p.m. documented, Not available. The August 2024 MAR documented the above order. On 8/18/24 at the 1:00 p.m. dose a 9 was documented. A 9 indicates Other/See Progress Note. The progress note dated 8/18/24 at 2:07 p.m. documented, not available. Review of the contents of the facility, onsite, pharmacy system, failed to have available, Meclizine. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked what she does if a medication is not on the medication cart at the scheduled time for administration, RN #5 stated she would first call the pharmacy. RN #5 was asked if the facility had a backup system for medications, RN#5 stated, yes, I would check there especially if the pharmacy were not open. When asked if the medication is not in the backup system, does she have to notify anyone, RN #5 stated, yes, we have to notify the provider and the responsible party for the resident. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure the physician reviewed and acted upon a pharmacy recommendation for one of five residents reviewed for the monthly pharmacy regimen review task. The findings include: For Resident #22, the facility staff failed to ensure the physician reviewed and addressed a pharmacy recommendation on 5/20/24. A review of the clinical record revealed a pharmacy note dated 5/20/24 that documented, See Consultant Pharmacist's Medication Regimen Review. A review of the pharmacy recommendation dated 5/20/24 documented, Resident is currently receiving Ramelteon (1) 8 mg (milligrams) tablets, 1 QHS (every night at bedtime) for hypnotic therapy and has been on it beyond the manufacturer's recommendation for duration of use. Please consider gradual tapering of the medication to ensure Resident is on the lowest dose possible, or continues to need the medication. The physician did not review and address this recommendation. The resident remained on this medication at this higher dose for an additional three months until the pharmacy repeated this recommendation on 8/12/24. The physician decreased the dose on 8/23/24 to 4 mg in response to the 8/12/24 recommendation. On 8/30/24 at 11:03 AM in an interview conducted with ASM #2 (Administrative Staff Member) the Director of Nursing, she stated that she gets the forms from pharmacy and they are provided to the provider who then addresses the recommendations and signs off on it. She stated she did not know why this one was not addressed timely. The facility policy, Medication Regimen Review documented, If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician .The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Ramelteon is used to help with insomnia Information obtained from https://medlineplus.gov/druginfo/meds/a605038.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure that one of five residents reviewed for the monthly pharmacy regimen review task was free of an unnecessary psychoactive medication; Resident #22. The findings include: For Resident #22, the facility staff failed to ensure the resident was free of an unnecessary psychoactive medication. A review of the clinical record revealed a physician's order dated 5/14/24 for Ramelteon (1) Oral Tablet 8 MG (milligrams) Give 1 tablet by mouth at bedtime for insomnia. A review of the pharmacy recommendation dated 5/20/24 documented, Resident is currently receiving Ramelteon (1) 8 mg (milligrams) tablets, 1 QHS (every night at bedtime) for hypnotic therapy and has been on it beyond the manufacturer's recommendation for duration of use. Please consider gradual tapering of the medication to ensure Resident is on the lowest dose possible, or continues to need the medication. The physician did not review and address this recommendation. The resident remained on this medication at this higher dose for an additional three months until the pharmacy repeated this recommendation on 8/12/24. The physician decreased the dose on 8/23/24 to 4 mg in response to the 8/12/24 recommendation. On 8/30/24 at 11:03 AM in an interview conducted with ASM #2 (Administrative Staff Member) the Director of Nursing, she stated that she gets the forms from pharmacy and they are provided to the provider who then addresses the recommendations and signs off on it. She stated she did not know why this one was not addressed timely. On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Ramelteon is used to help with insomnia Information obtained from https://medlineplus.gov/druginfo/meds/a605038.html

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in a safe and sanitary manner in one of one kitchen, and one of three nourishment rooms (the grace unit), and failed to maintain the dishwasher in good repair in one of one kitchen. The findings include: 1. The facility staff failed to store sugar in a safe and sanitary manner. On 8/26/24 at 12:10 p.m., an observation of the kitchen dry goods storage room was conducted. A container of sugar was observed with the lid open, exposing the sugar to air. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the lid should cover the sugar container at all times so nothing will drop into the sugar. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Receiving and Storage of Food documented, Foods shall be received and stored in a manner that complies with safe food handling practices. 2. The facility staff failed to store pots and a pan in a clean and sanitary manner. On 8/26/24 at 12:10 p.m., an observation of a food preparation table with two shelves was conducted. The lower shelf was observed with multiple brown and white stains and food debris. Two pots and one pan were observed upside down on the shelf, making contact with the shelf. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the food preparation table should be, wiped down daily and should not have stains and food debris on it. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 3. The facility staff failed to store an ice scoop in a sanitary manner. On 8/26/24 at 12:10 p.m., an observation of the kitchen ice machine was conducted. The ice scoop was lying on a cart beside the ice machine. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the maintenance department had ordered a hanger for the ice scoop and staff was supposed to place the ice scoop in a bag, but they forget. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 4. The facility staff failed to properly sanitize a bowl per the sanitizer solution manufacturer's instructions in the three-compartment sink. On 8/26/24 at 12:12 p.m., an observation of the three-compartment sink was conducted. A bowl was sitting in sanitizer solution. OSM #5 (a dietary cook) was asked to test the sanitizer solution. OSM #5 tested the sanitizer solution, and the reading was 170 ppm (parts per milliliter). OSM #5 and OSM #6 (another dietary cook) stated that was the appropriate amount of chemicals. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the sanitizer solution in the three-compartment sink should be 700 ppm. The sanitizer sink solution manufacturer's instructions documented, Testing solution should be between 0.27-0.55 oz/gal (ounces per gallon) corresponds to: 272-700 ppm. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 5. The facility staff failed to ensure the dishwasher ran at a safe temperature, per the manufacturer's instructions. On 8/26/24 at 1:10 p.m., an observation of the dishwasher was conducted while staff were washing facility dishes. The dishwasher temperature was 116 degrees Fahrenheit. On 8/27/24 at 9:15 a.m., an observation of the dishwasher was conducted while staff were washing facility dishes. The dishwasher temperature was 118 degrees. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the dishwasher should run between 120 to 123 degrees because it was a low temperature dishwashing machine. OSM #1 stated the staff had to run the dishwasher two or three times to obtain the proper temperature because the water came from a heat pump that was distanced farther away in the building. On 8/27/24 at 2:00 p.m., an observation of the dishwasher was conducted with OSM #1. The dishwasher gauge read 114 degrees. OSM #1 measured water in the dishwasher with a digital thermometer and the reading was 116.4. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The dishwasher manufacturer's instructions documented, WASH-(MINIMUM) 120. 6. The facility staff failed to serve coleslaw at a safe temperature. On 8/26/24 at 5:32 p.m., a meal test tray was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 measured the temperature of the coleslaw, and the temperature was 69 degrees Fahrenheit. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM #1. OSM #1 stated the coleslaw was a potentially hazardous food and should be served at a temperature of 40 degrees. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 7. The facility staff failed to label and store watermelon in a safe manner. On 8/27/24 at 9:20 a.m., an observation of the grace unit nourishment room refrigerator was conducted with RN (registered nurse) #4. A container of mushy dark watermelon pieces in a cloud of juice was observed. The container was not labeled with a date. RN #4 stated the container should have been labeled with a date and the contents in the container looked like old watermelon with an unpleasant odor. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to provide a sanitary environment for one of one kitchen. The findings include: The facility staff failed to ensure the floors in the kitchen were clean and free from debris. On 8/26/24 at 12:10 p.m., and 8/27/24 at 9:15 a.m., observations of the kitchen were conducted. Several crumbles of black and brown debris were easily visible and observed on the floor under the three-compartment sink, under shelves, under the dishwasher, and in a gap (approximately 12 inches) between the stove and ovens. Several crumbles of black and brown debris and black and brown stains were observed on the floor in the dry goods storage room. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the dietary staff should sweep and mop the kitchen floors after every meal and this should be done under the sink, under shelves, under the dishwasher, and between the stove and ovens. OSM #1 stated the dietary staff could not remove the stains on the floor in the dry goods storage room and she had asked the housekeeping staff to strip and wax the floor. All of the above areas were observed with OSM #1, and she stated the floors needed to be cleaned. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Floors documented, Floors shall be maintained in a clean, safe, and sanitary manner. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #67 (R67), the facility staff failed to promote dignity on 9/30/23 during the night shift (11:00 p.m. to 7:00 a.m.), the staff failed to provide ADL (activities of daily living) assistance or assist the resident to bed. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, R67 scored seven out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The resident was assessed as being dependent on staff for toileting, personal hygiene and transfers. The quarterly MDS assessment with an ARD of 12/8/23 documented R67 scoring 15 out of 15 on the BIMS assessment, indicating they were cognitively intact for making daily decisions at that time, and being dependent on staff for toileting, personal hygiene and transfers. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under hospice care. R67's family member stated that they had multiple concerns regarding the care that was received at the facility and stated that on 9/30/23, R67 had been left sitting up in the wheelchair all night long after returning to the facility from a leave with family. She stated that R67 had asked the staff to put them back to bed and they had not done it and the staff had told them that it was because R67 was refusing to go to bed. She stated that R67 had been left sitting in the wheelchair in soiled clothing and not assisted back to bed the entire night and not cleaned up until the day shift staff got there the next day. The progress notes for R67 documented in part, - 09/29/2023 07:50 Note Text: Resident went OOF (out of facility) this morning as per his routine, facility aware. Resident had morning meds w/o difficulty before leaving. - 09/30/2023 22:42 (10:42 p.m.) Note Text: Aide offered to put resident down after writer finished medication pass, refused 3x to go to bed and stated wanted to sit on commode for an hour before bed advised that due to pressure sore risks and skin integrity complications that this was strongly advised against. Brief on and intact, offered to help change brief, denied assistance. Passed in report that resident refused help offered to him. The progress notes for R67 failed to evidence documentation of any further attempts to provide care to R67 during the night shift on 9/30/2023 or refusal of care. Review of the ADL documentation report for R67 dated 9/1/23-9/30/23 failed to evidence any ADL care provided, transfer assistance provided, refusal of care or behaviors displayed by R67 on the night shift (11:00 p.m. to 7:00 a.m.) shift of 9/30/23. The comprehensive care plan for R67 documented in part, [Name of R67] has an ADL self-care performance deficit AEB (as evidenced by) spinal stenosis, osteoarthritis, & pain. Date Initiated: 02/01/2024. Revision on: 02/01/2024. Under Interventions it documented in part, .Physical assist as needed with ADLs. Date Initiated: 05/30/2023. Revision on: 06/14/2023 . On 8/28/24 at approximately 8:45 a.m., ASM (administrative staff member) #1, the administrator stated that the RN (registered nurse) who wrote the progress note on 9/30/23 and the CNA (certified nursing assistant) who worked on the unit that R67 resided on 9/30/23, no longer worked at the facility. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA #7. CNA #7 stated that residents were rounded on every two hours to check for needs such as incontinence care, water, pain and turning and repositioning. She stated that the care that they provided to the resident was evidenced as done by their documentation in the ADLs each shift in the computer. She stated that she was not aware of any residents who would be left up in their wheelchair all night unless that was what they requested or if it was a behavior and it would be reported to the nurse and documented. She stated that when she worked with R67, they were complaint with care. On 8/30/24 at 10:00 a.m., an interview was conducted with CNA #8. CNA #8 stated that when a resident refused care, they let the nurse know and returned to the resident later with the nurse to re-attempt the care. She stated that if the resident still refused the care it was documented in the medical record in the ADLs and the nurse also documented the refusal and reported it. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Based on observation, resident interview, facility staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a manner to promote resident dignity for four of 50 residents in the survey sample, Residents #96, #31, #67, and #157. The findings include: 1. For Resident #96 (R96), the facility staff failed to treat him with dignity after he vomited. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated that last Saturday, 8/24/24, he woke up very early in the morning, around 6:00 a.m. LPN (licensed practical nurse) #4 was at his bedside administering a tube feeding. As LPN #4 walked away from his bed towards the bathroom, he experienced severe nausea. He called out to the nurse, then vomited a large amount. He stated he caught some of the emesis in a basin, but much of it landed on his clothing and bed linens. He stated a CNA (certified nursing assistant) came in the room, but he could not remember the CNA's name. He stated the CNA placed a clean towel over his chest, and walked out of the room, along with LPN #4. He stated no one came in to clean him up and change his bed linens until after 9:00 a.m. that morning. He stated this made him feel dirty and humiliated. A review of R96's clinical record revealed no evidence of this incident. On 8/29/24 at 7:30 a.m., LPN #4 were interviewed. She stated she remembered the morning that R96 vomited. She had worked the night shift, and was providing the resident's early morning tube feeding. She stated within about five minutes of finishing administering his tube feeding, he vomited it all back up. She stated the CNA working with her put a towel across the resident's chest, and walked out the door with her. She stated: I thought she was going to get supplies to clean him up. She stated if the resident was left dirty for several hours, the resident was not being treated with dignity. The CNA in question was not available for interview during the survey. A review of R96's care plan dated 7/12/24 revealed, in part: [R96] has an ADL self-care deficit .Physical assist as needed. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. A review of the facility policy, Dignity, revealed, in part: Each resident shall be cared for in a manner that promotes or enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents will be treated with dignity and respect at all times. No further information was provided prior to exit. 2. For Resident #31 (R31), the facility staff failed to serve lunch in a dignified manner. Other residents seated at the same table as R31 were served a meal and R31 was not served food until 11 minutes later. On 8/26/24 at 12:52 p.m., R31 was observed sitting at a table in the dining room. At this time, two other residents were observed seated at the same table and eating lunch. R31 was not served any food until 1:03 p.m. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the dietary aides were responsible for serving meals in the dining room and everyone at the same table should be served food at the same time so no resident is just sitting there waiting. OSM #1 stated that if she was seated at a table where other residents were eating and she was not served, I would be like where is my food? On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food and Nutrition Services failed to document information regarding a diginified dining experience. No further information was presented prior to exit. 4. For Resident #157 (R157), the facility staff failed to treat the resident in a dignified manner, telling the resident to void in her brief. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/13/24, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section H - Bladder and Bowel, the resident was coded as being occasionally incontinent of urine and frequently incontinent of bowel. An interview was conducted with R157 on 8/26/24 at 3:55 p.m. When asked if the staff treat her with dignity and respect, R157 stated when she has to go to the bathroom, the staff tell her to pee in your diaper. She stated the staff tell her they are going on break and can't change her at that time. When asked how that makes her feel, R157 stated that it's embarrassing to go in the brief and makes her feel bad. R157 stated that when she has to wait and can't hold her urine any longer, she voids in the brief and many times it goes through to her clothing, so she is soaking wet. She stated that is not a good feeling to be wet. An interview was conducted with CNA (certified nursing assistant) #7 on 8/29/24 at 11:15 a.m. When asked if a resident puts on their call bell for assistance, what does she do, CNA #7 stated if she is available, she will assist the resident, if she is not available she will get someone else to assist the resident. Have you ever told or heard a staff member tell a resident to pee in their diaper, CNA #7 stated, no. CNA #7 was asked if she has ever or heard anyone tell a resident they have to wait for assistance as they are going on break, CNA #7 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #45 (R45), the facility staff failed to evidence that written notification of transfer was provided to the resident and/or responsible party and the long-term care ombudsman for a facility-initiated transfer on 8/5/24 and failed to evidence notification of transfer provided to the long-term care ombudsman for facility-initiated transfers on 4/29/24 and 6/25/24. A review of R45's clinical record revealed the following progress notes: - 04/29/2024 15:04 (3:04 p.m.) Note Text: Resident complained of pain while urinating at about 9.30 this morning. Informed resident that the NP (nurse practitioner) would be in to see him today. [NAME] [sic] I wrote his name down in the provider book. Around 12pm resident complained that when urinating that his foreskin was Ballooning and he now had blood in his urine. NP notified and orders to send resident to ER for evaluation for possible stricture and hematuria. 911 called, [Name of hospital] notified, RP (responsible party) notified, resident is being transported to ER. - 06/25/2024 06:52 (6:52 a.m.) Note Text: Patient transferred to ED for SOB (shortness of breath), chest pain, chills and fever. Report received from [Name of hospital] from charge nurse [Name of nurse] that patient was admitted for Sepsis, Pneumonia, and possible respiratory failure. RP-sister [Name of RP] was called and made aware. DON (director of nursing) also aware. - 08/05/2024 20:16 (8:16 p.m.) Note Text : while passing medication on hall heard resident yelling upon entering resident room supervisor, second nurse and CNA (certified nursing assistant) was in resident room resident was laying on floor next to bed and w/c (wheelchair) c/o (complains of) back, neck, r/l (right/left) arm and leg pain when ask resident what happened resident stated I passed out while sitting in w/c and fell left resident room to call on call NP and gather paperwork leaving behind with resident supervisor, second nurse and CNA on call NP called spoke with [Name of NP], 911 called, report called in to [Name of hospital] ER resident exit facility with Ems (emergency medical services) to hospital for evaluation. Further review of the clinical record failed to reveal evidence that notification of transfer was provided to the long-term care ombudsman for the transfers on 4/29/24 and 6/25/24. It further failed to evidence that written notification of transfer was provided to the resident and/or the responsible party and the long-term care ombudsman for the transfer on 8/5/24. On 8/27/24 at 3:50 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of notification of transfer provided to the long-term care ombudsman for the transfers on 4/29/24 and 6/25/24 and written notification of transfer was provided to the resident and/or the responsible party and the long-term care ombudsman for the transfer on 8/5/24. On 8/28/24 at 8:36 a.m., ASM #1 stated that they did not have any evidence to provide. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent out to the emergency room the nurse sent a copy of the physician orders, the care plan, bed hold notice, transfer summary and the change in condition note. She stated that they had transfer folders at the nurse's station that contained a checklist of documents to send out with the resident, so the staff knew what needed to be sent. She stated that nursing did not send anything to the ombudsman. On 8/28/24 at 10:52 a.m., an interview was conducted with OSM (other staff member) #4, discharge planner. OSM #4 stated that they sent out ombudsman notification of transfers monthly from a report they printed out and they kept a copy of it in a file with the email confirmation. She stated that she followed up on transfers the next day and sent out the written notices by certified mail and kept the letter on file afterwards. She stated that she had been out for a while, and some had been missed when she was out. She stated that she did not have evidence of the ombudsman notification or written notices for R45 for the dates listed above. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN (registered nurse) #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. 5. For Resident #11 (R11), the facility staff failed to evidence notification of transfer provided to the long-term care ombudsman for facility-initiated transfer on 7/28/24. A review of R11's clinical record revealed the following physician order: - Transfer to ED for further evaluation. 07/28/2024. Further review of the clinical record failed to reveal evidence notification of transfer provided to the long-term care ombudsman for facility-initiated transfer on 7/28/24. On 8/27/24 at 3:50 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of ombudsman notification for the facility-initiated transfer on 7/28/24. On 8/28/24 at 8:36 a.m., ASM #1 stated that they did not have any evidence of ombudsman notification to provide. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent out to the emergency room the nurse sent records to the hospital, but they did not send anything to the ombudsman. On 8/28/24 at 10:52 a.m., an interview was conducted with OSM (other staff member) #4, discharge planner. OSM #4 stated that they sent out ombudsman notification of transfers monthly from a report they printed out and they kept a copy of it in a file with the email confirmation. She stated that she had been out for a while, and some had been missed when she was out. She stated that she did not have evidence of the ombudsman notification for R11 for the date listed above. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN (registered nurse) #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence written notification of a facility-initiated hospital transfer was provided to the resident and/or Ombudsman, for five of 50 residents in the survey sample; Residents #52, #69, #22, #45 and #11. The findings include: 1. For Resident #52, the facility staff failed to evidence a written notice was provided to the resident representative for a hospital transfer on 7/11/24. A review of the clinical record revealed a nurse's note dated 7/11/24 that documented, Resident has complaint of shortness of breath and states My chest feels heavy. On call MD notified of current condition and order given to this nurse to send to ER (Emergency Room) for evaluation and treatment as indicated Further review of the clinical record failed to reveal any evidence of a written noticed being provided to the resident representative regarding the hospital transfer. On 8/30/24 at 8:50 AM an interview was conducted with OSM #4 (Other Staff Member) the Discharge Planner / Social Worker. She stated that she was out with COVID and did not send out the written notification to the resident representative upon her return. The facility policy, Facility Initiated Transfer and Discharge was reviewed. This policy documented, 6. Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident ' s return is generally expected 8. Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand b. Notice must be made as soon as practicable before transfer or discharge when: .An immediate transfer or discharge is required by the resident ' s urgent medical needs .The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #69, the facility staff failed to evidence a written notice was provided to the resident representative and the Ombudsman for a hospital transfer on 7/12/24. A review of the clinical record revealed a nurse's note dated 7/12/24 that documented, Called NP (nurse practitioner) earlier because resident was tachycardic and had an elevated temp and slightly elevated temps. NP came an assessed resident and stated she will do labs on resident. As the afternoon progressed resident noted to be more confused, restless and difficult to redirect. called Np and she stated ok to transfer resident to hospital. Further review of the clinical record failed to reveal any evidence of a written noticed being provided to the resident representative and Ombudsman regarding the hospital transfer. On 8/30/24 at 8:50 AM an interview was conducted with OSM #4 (Other Staff Member) the Discharge Planner / Social Worker. She stated that she was out with COVID and did not send out the written notification to the resident representative upon her return. She provided the list she submitted to the Ombudsman for July 2024 transfers and discharges, which did not include Resident #69's name. It was noted that the transfer list did not capture the names of residents who went to the emergency room and back on the same day and were not discharged from the system. The facility policy, Facility Initiated Transfer and Discharge was reviewed. This policy documented, 6. Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident ' s return is generally expected 8. Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand b. Notice must be made as soon as practicable before transfer or discharge when: .An immediate transfer or discharge is required by the resident ' s urgent medical needs .The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #22, the facility staff failed to evidence a written notice was provided to the Ombudsman for a hospital transfer on 6/26/24. A review of the clinical record revealed a nurse's note dated 6/26/24 that documented, Resident returned from dialysis at 1145 (11:45 AM), nosebleed in progress. Pressure applied continuously; bleeding continued. NP (nurse practitioner) contacted; order received to send to ED (emergency department) at this time Further review of the clinical record failed to reveal any evidence of a written noticed being provided to the Ombudsman regarding the hospital transfer. On 8/30/24 at 8:50 AM an interview was conducted with OSM #4 (Other Staff Member) the Discharge Planner / Social Worker. She provided the list she submitted to the Ombudsman for June 2024 transfers and discharges, which did not include Resident #22's name. It was noted that the transfer list did not capture the names of residents who went to the emergency room and back on the same day and were not discharged from the system. The facility policy, Facility Initiated Transfer and Discharge was reviewed. This policy documented, 6. Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident ' s return is generally expected 8. Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand b. Notice must be made as soon as practicable before transfer or discharge when: .An immediate transfer or discharge is required by the resident ' s urgent medical needs .The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. The facility staff failed to implement the comprehensive care plan for wound care for Resident #116. Resident #116 was admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, sacral ulcer and ASCVD (atherosclerotic cardiovascular disease). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/6/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 9/14/22 revealed, FOCUS: Resident has a skin tear to her right shin. INTERVENTIONS: Treatment as ordered. A review of the physician orders dated 12/24/22 revealed, Cleanse wound to right lower leg and Left forearm with wound cleanser, apply xeroform gauze to wound, cover with kerlix, secure with tape. One time a day for skin tear. A review of the December 2022, January 2023 and February 2023 MAR (medication administration record) revealed missing evidence of wound treatments provided on the following dates: 12/28/22, 12/30/22, 12/31/22, 1/2/23, 1/3/23, 1/13/23, 1/16/23, 1/21/23 1/24/23, 1/31/23, and 2/7/23. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked what the purpose of the comprehensive care plan is, LPN #2 stated, to develop the plan of care that is individualized for each resident. When asked if a resident's care plan includes wound care and there is no evidence that is has been completed, has the care plan be implemented, LPN #2 stated, no, it has not been. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Care Planning policy revealed in part, Our Care Planning team is responsible for the development of an individualized comprehensive care plan for each resident. No further information was provided prior to exit. 4. For Resident #67 (R67), the facility staff failed to implement the comprehensive care plan to provide physical assistance with ADLs (activities of daily living) on 9/30/23 and multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, the resident scored seven out of 15 on the BIMS (brief assessment for mental status), indicating R67 was severely impaired for making daily decisions. Section GG documented R67 being dependent on staff for toileting, bathing, dressing, bed mobility, transfers, and personal hygiene. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under hospice care. R67's family member stated that they had multiple concerns regarding the care that was received at the facility and stated that on 9/30/23, R67 had been left sitting up in the wheelchair all night long after returning to the facility from a leave with family. She stated that R67 had asked the staff to put them back to bed and they had not done it and the staff had told them that it was because R67 was refusing to go to bed. She stated that R67 had been left sitting in the wheelchair in soiled clothing and not assisted back to bed the entire night and not cleaned up until the day shift staff got there the next day. R67's family member further stated that the staff did not come in to turn and reposition every two hours and left the resident soiled for extended periods of time. She stated that R67 could not turn themselves and relied on the staff to come in to turn them, but she often found him lying in one position the entire time she was there to visit. She stated that since hospice had come on board that they had been providing most of the care to R67. The comprehensive care plan for R67 documented in part, [Name of R67] has an ADL self-care performance deficit AEB (as evidenced by) spinal stenosis, osteoarthritis, & pain. Date Initiated: 02/01/2024. Revision on: 02/01/2024. Under Interventions it documented in part, .Physical assist as needed with ADLs. Date Initiated: 05/30/2023. Revision on: 06/14/2023 . Review of the ADL documentation report for R67 dated 9/1/23-9/30/23 failed to evidence any ADL care provided, transfer assistance provided, refusal of care or behaviors displayed by R67 on the night shift (11:00 p.m. to 7:00 a.m.) shift for 9/30/23. Review of the ADL documentation report for R67 dated 6/1/24-6/30/24 failed to evidence assistance with bed mobility provided on day shift on 6/14/24 and 6/30/24, and on evening shift on 6/14/24, 6/17/24, 6/21/24 and 6/23/24. It further failed to evidence assistance with bed mobility on night shift on 6/1/24, 6/4/24, 6/7/24, 6/8/214, 6/11/24, 6/15/24, 6/19/24, 6/22/24, 6/28/24 and 6/30/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . Review of the ADL documentation report for R67 dated 7/1/24-7/31/24 failed to evidence assistance with bed mobility provided on day shift on 7/4/24, and on night shift on 7/2-7/8/24, 7/10-7/22/24, 7/24-7/27/24, 7/30/24 and 7/31/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . Review of the ADL documentation report for R67 dated 8/1/24-8/30/24 failed to evidence assistance with bed mobility provided on day shift on 8/17/24, and on evening shift on 8/17/24 and 8/21/24. If further failed to evidence assistance with bed mobility on night shift on 8/2/24, 8/4/24, 8/10-8/12/24, 8/17/24, 8/19/24, 8/21/24, 8/23/24, and 8/28/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . The progress notes for R67 documented in part, - 09/29/2023 07:50 Note Text: Resident went OOF (out of facility) this morning as per his routine, facility aware. Resident had morning meds w/O difficulty before leaving. - 09/30/2023 22:42 (10:42 p.m.) Note Text: Aide offered to put resident down after writer finished medication pass, refused 3x to go to bed and stated wanted to sit on commode for an hour before bed advised that due to pressure sore risks and skin integrity complications that this was strongly advised against. Brief on and intact, offered to help change brief, denied assistance. Passed in report that resident refused help offered to him. The progress notes for R67 failed to evidence documentation of any further attempts to provide care to R67 during the night shift on 9/30/2023 or refusal of care. On 8/28/24 at approximately 8:45 a.m., ASM (administrative staff member) #1, the administrator stated that the RN (registered nurse) who wrote the progress note on 9/30/23 and the CNA (certified nursing assistant) who worked on the unit that R67 resided on 9/30/23, no longer worked at the facility. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA #7. CNA #7 stated that residents were rounded on every two hours to check for needs such as incontinence care, water, pain and turning and repositioning. She stated that the care that they provided to the resident was evidenced as done by their documentation in the ADLs each shift in the computer. She stated that she was not aware of any residents who would be left up in their wheelchair all night unless that was what they requested or if it was a behavior and it would be reported to the nurse and documented. She stated that when she worked with R67, they were complaint with care. She stated that R67 required staff to turn and reposition them and they documented the care provided under bed mobility. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that the care plan purpose was for the staff to have a complete person-centered plan that showed what needed to be done for the resident. She stated that the care plan should be followed and the whole care team was responsible for making sure the care plan was implemented. On 8/30/24 at 10:00 a.m., an interview was conducted with CNA #8. CNA #8 stated that when a resident refused care, they let the nurse know and returned to the resident later with the nurse to re-attempt the care. She stated that if the resident still refused the care it was documented in the medical record in the ADLs and the nurse also documented the refusal and reported it. She stated that if NA was documented in the ADLs it meant not applicable and usually the resident was out at an appointment or not in the building at that time. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. 5. For Resident #111 (R111), the facility staff failed to implement the comprehensive care plan to provide treatment to a pressure injury (1) as ordered on multiple dates from 9/1/23-12/31/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/2/24, the resident was assessed as having one Stage 2 pressure injury that was not present on admission. The comprehensive care plan for R111 documented in part, [Name of R111] has an unstageable pressure ulcer (see wound nurse note 3/24/2023) on her sacrum r/t decreased mobility, incontinence. Date Initiated: 05/05/2023. Revision on: 11/02/2023. Under Interventions it documented in part, Apply treatments as ordered and monitor for effectiveness. Date Initiated: 05/05/2023. Revision on: 11/02/2023. The progress notes for R111 documented in part, 6/7/2023 16:18 (4:18 p.m.) Weekly wound assessment completed. Unstageable Pressure Ulcer to other: Sacral. Overall impression: new wound- first observation. See wound evaluation weekly for additional details . The physician orders for R111 documented in part, Clean area to sacrum with normal saline or soap and water apply barrier cream cover with foam dressing qday (every day) and prn (as needed) when soiled. every day shift for assessment. Review of the eTAR (electronic treatment administration record) for R111 dated 9/1/23-9/30/23 failed to evidence a treatment completed as ordered to the sacral area on 9/4/23, 9/9/23, 9/11/23, 9/15-9/18/23, 9/21/23, 9/23/23, and 9/28/23. Review of the eTAR for R111 dated 10/1/23-10/31/23 failed to evidence a treatment completed as ordered to the sacral area on 10/6/23, 10/7/23, and 10/24/23. Review of the eTAR for R111 dated 11/1/23-11/30/23 failed to evidence a treatment completed as ordered to the sacral area on 11/17/23. Review of the eTAR for R111 dated 12/1/23-12/31/23 failed to evidence a treatment completed as ordered to the sacral area on 12/1/23, 12/7/23, 12/16/23, 12/17/23, 12/19/23, and 12/22-12/24/23. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to show the staff what they were supposed to do for the resident. She stated that it was their treatment plan, and it should be implemented because it was the residents right to have goals and to see the outcomes. She stated that the wound nurse was there during the week and when she was not there the floor nurses were expected to complete the wound care treatments. She stated that the wound care was evidenced by the nurse writing the time, date, and initials on the dressing and signing them off as completed on the eTAR. On 8/28/24 at 11:39 a.m., an interview was conducted with RN (registered nurse) #3, wound care. RN #3 stated that they had been at the facility for about two months and prior to them starting the floor nurses were doing the wound care treatments. She stated that wound care was evidenced as done by the nurse signing off on the eTAR and if not completed or the resident was not available for the wound care it would be documented on the eTAR and the provider would be made aware. On 8/29/24 at 12:40 p.m., an interview was conducted with RN #5. RN #5 stated that the care plan purpose was for the staff to have a complete person-centered plan that showed what needed to be done for the resident. She stated that the care plan should be followed and the whole care team was responsible for making sure the care plan was implemented. On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN (registered nurse) #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. 6. For Resident #24 (R24), the facility staff failed to implement the comprehensive care plan to provide catheter care on multiple dates from 6/1/24 through 7/30/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/14/24, the resident scored 15 out of 15 on the BIMS (brief assessment for mental status), indicating R24 was cognitively intact for making daily decisions. Section H documented R24 having an indwelling catheter. On 8/26/24 at 2:18 p.m., an interview was conducted with R24 in their room. A urinary catheter bag was observed attached to the bed frame of R24's bed with a privacy cover intact. R24 stated that they had a urinary catheter and had it for a few years now which they saw the urologist for regularly. R24 stated that the staff changed the catheter when it was leaking and emptied the bag every day. R24 stated that the staff kept gauze around the catheter site and changed it when it came off. R24 stated that they were unsure if there was a schedule for catheter care of not. The comprehensive care plan for R24 documented in part, [Name of R24] has Suprapubic (1) Catheter: Obstructive Uropathy. Date Initiated: 07/29/2022. Revision on: 09/07/2022. Under Interventions it documented in part, .Catheter care Q (every) shift and PRN (as needed). Date Initiated: 07/29/2022 . The physician orders for R24 documented in part, - Order Date: 06/06/2022. Cath care every shift and as needed- may be performed by CNA (certified nursing assistant), verified by nurse every shift. End Date: 06/06/2024. - Order Date: 08/02/2024. Foley cath care every shift and prn (as needed). every shift related to Neuromuscular dysfunction of bladder, unspecified. - Order Date: 06/26/2024. regular gauze cut with split to place around suprapubic catheter, Zinc oxide to periwound daily and PRN for soilage and or dislodgement. as needed for soilage and or dislodgement AND every day shift. Review of the eTAR (electronic treatment administration record) for R24 dated 6/1/24-6/30/24 failed to evidence catheter care provided 6/4/24-6/26/24. Review of the eTAR for R24 dated 7/1/24-7/31/24 failed to evidence catheter care provided on 7/26/24 and 7/29/24. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 stated that catheter care was provided every shift. She stated that they emptied the catheter bags and cleaned the skin around the catheter unless there was a special treatment ordered and then the nurse did the treatment. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that the care plan purpose was for the staff to have a complete person-centered plan that showed what needed to be done for the resident. She stated that the care plan should be followed and the whole care team was responsible for making sure the care plan was implemented. She stated that residents with suprapubic catheters had the site assessed and the care was provided as ordered by the physician. She stated that the orders triggered on the eTAR for the nurse to complete the treatment and document it as completed. She stated that the documentation was how the care was evidenced as completed. She stated that if there were no orders for the catheter the physician should be called to get orders for care. On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. You may need a catheter because you have urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made a catheter necessary, or another health problem. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/000145.htm. 8. For Resident #63 (R63), the facility staff failed to follow the resident's dialysis care plan for a fluid restriction. A review of R63's clinical record revealed the following order dated 8/23/24: Fluid restriction =1200 ml/day (milliliters per day): dietary 840 ml/day (B [breakfast]: 240 ml, L [lunch]: 360 ml, D [dinner]: 240 ml); nursing - 360 ml/day (120 ml q [each] shift). Further review of R63's clinical record, including August 2024 MARs (medication administration records), TARs (treatment administration records), and progress notes, revealed no evidence that the fluid restriction had been implemented. A review of R63's care plan revealed, in part: [R63] has nutritional problem or potential nutritional problem r/t (related to) .ESRD (end stage renal disease) .Fluid restriction 1200 ml/day (milliliters per day): dietary 840 ml/day (B [breakfast]: 240 ml, L [lunch]: 360 ml, D [dinner]: 240 ml); nursing - 360 ml/day (120 ml q [each] shift). On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated the dietician is responsible for putting an order in for any kind of fluid restriction. It is the nurses' responsibility to document the resident's fluid intake on each shift. After reviewing R63's order, MAR, and TAR, she stated: There is no documentation about this order because it was put in as 'no documentation required.' The dietician put the order in wrong. LPN #5 stated R63 receives dialysis, and the fluid restriction is intended to prevent the resident from becoming fluid overloaded. On 8/29/24 at 12:40 p.m., RN (registered nurse) #5, a unit manager, was interviewed. She stated the care plan is inclusive and person-centered for each resident. She stated it's the one place staff members can go to see what needs to be done. She added, it is the responsibility of the whole care team to make sure the care plan is followed. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 9. For Resident #96 (R96), the facility staff failed to implement the resident's care plan to administer multiple sclerosis medication per physician order. A review of R96's clinical record revealed the following physician order dated 7/13/24: Avonex Prefilled Intramuscular Prefilled Syringe Kit 30 mcg/0.5 ml (micrograms per milliliter). Inject 1 syringe intramuscularly one time a day every Sat (Saturday) related to multiple sclerosis. Family to bring from home. A review of R96's progress notes revealed, in part: 8/3/24 [Avonex] not given. Not available. Waiting on family. 8/10/24 [Avonex] not given .waiting on the family to bring in. 8/10/24 [Avonex] not given .waiting on family. A review of R96's August 2024 MAR (medication administration record revealed that R96 did not receive the medication on any of the three Saturdays in August prior to survey entrance. Instead of Saturday, 8/3/24, the resident received the medication on Tuesday, 8/6/24. The resident then received the medication on subsequent Tuesdays 8/13 24 and 8/20/24. This review R96 did not receive Avonex between 7/27/24 and 8/6/24, a total of 10 days between administrations. The clinical record review revealed no evidence of efforts by the facility to communicate with the pharmacy or the family regarding the resident's Avonex availability. A review of R96's care plan dated 7/18/24 revealed, in part: [R96] has multiple sclerosis .Give medications as ordered. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. When asked about R96's Avonex injections, she stated: The wife brings it in. There has been an issue with the wife bringing the medication on the day it needs to be given. I know that on one Saturday, it wasn't given because it wasn't here to be given. She stated she is aware the medication is very expensive, and she did not know what to do if the wife did not bring the medication to the facility for the nurses to administer to R96. On 8/29/24 at 12:40 p.m., RN (registered nurse) #5, a unit manager, was interviewed. She stated the care plan is inclusive and person-centered for each resident. She stated it's the one place staff members can go to see what needs to be done. She added, it is the responsibility of the whole care team to make sure the care plan is followed. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the No further information was provided prior to exit. Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for nine of 50 residents in the survey sample, Residents #157, #101, #34, #67, #111, #24, #116, #63, and #96. The findings include: 1a. For Resident #157 (R157), the facility staff failed to implement the comprehensive care plan to do the blood sugars per the physician orders. The comprehensive care plan dated 8/21/24, documented in part, Focus: (R157) has Diabetes Mellitus. The interventions documented in part, Fasting Serum Blood Sugar as ordered by doctor. The physician order dated 8/9/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals and at bedtime for diabetes. D/C (discontinue date) 8/18/24. The blood sugars are scheduled for 7:00 a.m., 11:00 a.m., 4:00 p.m. and 9:00 p.m. The physician order dated 8/12/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals for diabetes. The blood sugars are scheduled for 6:30 a.m., 11:00 a.m. and 4:00 p.m. The physician order dated 8/23/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451 - 500 = 14 units. subcutaneously before meals for diabetes. The blood sugars are scheduled for 6:30 a.m., 11:00 a.m. and 4:00 p.m. The documented mealtimes for the facility are: Breakfast - 7:30 a.m. Lunch - 12:00 p.m. Dinner - 5:00 p.m. The August 2024 MAR (medication administration record) documented the above orders. On the following dates and times, the blood sugars were taken during or after the meals: 8/10/24 at 5:48 p.m. - scheduled for 4:00 p.m. 8/11/24 at 5:50 p.m. - scheduled for 4:00 p.m. 8/12/24 at 9:20 a.m. - scheduled for 7:00 a.m. 8/12/24 at 5:39 p.m. - scheduled for 4:00 p.m. 8/13/24 at 12:02 p.m. - scheduled for 11:00 a.m. 8/13/24 at 6:41 p.m. - scheduled for 4:00 p.m. 8/21/24 at 6:25 p.m. - scheduled for 4:00 p.m. 8/23/24 at 12:48 p.m. - scheduled for 11:00 a.m. 8/24/24 at 6:60 p.m. - scheduled for 4:00 p.m. 8/26/24 at 10:21 p.m. - scheduled for 4:00 p.m. 8/27/24 at 1:10 p.m. - scheduled for 11:00 a.m. 8/28/24 at 1:41 p.m. - scheduled for 11:00 a.m. An interview was conducted with ASM (administrative staff member) #4, the nurse practitioner, on 8/29/24 at 9:54 a.m. When asked why a resident is on sliding scale insulin, ASM #4 stated, to help cover them when the blood sugars are higher when the resident has eaten sugary snacks. ASM #4 was asked what times they are normally ordered, ASM #4 stated before meals and at bedtime. When asked what would happen if the blood sugar was taken after the resident ate their meal, ASM #4 stated, it depends, if they've only eaten five bites or so, then nothing, but if they've eaten their whole meal, say 30 minutes to an hour later, it would elevate the blood sugar, thus giving them too much insulin and the risk of their blood sugar going too low. An interview was conducted with RN (registered nurse) #5, the unit manager, on 8/29/24 at 12:40 p.m. When asked the purpose of the care plan, RN #5 stated it's to have a conclusive person-centered plan, one area you can go to see what needs to be done for the resident. RN#5 was asked if it should be followed, RN #5 stated, yes. When asked who is responsible for implementing the care plan, RN #5 stated, the whole care team. The facility policy, Care Planning - Comprehensive Person-Centered, documented in part, 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 1b. For Resident #157, the facility staff failed to implement the comprehensive care plan to administer insulin per the physician orders. The comprehensive care plan dated 8/21/24, documented in part, Focus: (R157) has Diabetes Mellitus. The interventions documented in part, Diabetes medication as ordered by doctor. The physician order dated 8/23/24 documented, Levemir Flex Pen Subcutaneous Solution Pen- Injector 100 UNIT/ML; Inject 50 units subcutaneously at bedtime for DM (diabetes mellitus). The August 2024 MAR documented the above order. On 8/24/24, there was a blank on the space for the medication to be documented as administered. Review of the nurse's notes failed to evidence documentation of a reason why the medication was not given. An interview was conducted with RN (registered nurse) #5, the unit manager, on 8/29/24 at 12:40 p.m. When asked the purpose of the care plan, RN #5 stated it's to have a conclusive person-centered plan, one area you can go to see what needs to be done for the resident. RN#5 was asked if it should be followed, RN #5 stated, yes. When asked who is responsible for implementing the care plan, RN #5 stated, the whole care team. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations, and ASM #9, the regional director of clinical services, were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was obtained prior to exit. 1c. For Resident #157, the facility staff failed to implement the comprehensive caer plan to administer antibiotics in a timely manner. The comprehensive care plan dated, 8/23/24, documented in part, Focus: (R157) is on antibiotic therapy r/t (related to) abscess to right buttock. The Interventions documented in part, Administer ANTIBIOTIC medications as ordered by physician. The physician order dated 8/22/24 at 3:42 p.m. documented, Clindamycin HCL (hydrochloride) 150 MG; give 3 capsules by mouth three times a day for abscess to buttocks for 10 days. The medication was scheduled for 7:00 a.m., 11:00 a.m. and 8:00 p.m. The August 2024 MAR documented the above order. The first dose was documented as having been given on 8/23/24 at 7:00 a.m. On 8/24/24 at the scheduled 8:00 p.m. dose, nothing was documented in the space. Review of the contents of the facility, onsite, pharmacy system, documented the Clindamycin 150 mg was available in the system. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked if a physician order is written on 8/22/24 for an antibiotic, when would the antibiotic be started, RN #5 stated, on the 22nd, if it was started on the 23rd, it would be a delay in treatment. When asked how she evidenced that she's given a medication, RN #5 stated she documents in on the electronic MAR. When asked the purpose of the care plan, RN #5 stated it's to have a conclusive person centered plan, one area you can go to see what needs to be done for the resident. RN#5 was asked if it should be followed, RN #5 stated, yes. When asked who is responsible for implementing the c[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.The facility staff failed to provide evidence of incontinence care for dependent Resident #108. Resident #108 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CAD (coronary artery disease), COPD (chronic obstructive respiratory disease), hyponatremia and asthma. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 5/20/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan with a revision date of 5/16/24, revealed, FOCUS: The resident has bladder incontinence related to decrease mobility weakness. INTERVENTIONS: Physical assist as needed with ADLs. Provide supervision and cuing as needed with ADLs. A review of the May 2024 ADL (activities of daily living) record revealed missing documentation for incontinence care, bathing and dressing on the following shifts and dates: Night: 5/15/24 and 5/19/24. An interview was conducted on 8/27/24 at 8:10 AM with CNA (certified nursing assistant) #1. When asked the process for incontinence care, CNA #1 stated, we round every two to three hours and provide the incontinence care, turning/repositioning at those times. When asked where the incontinence care would be evidenced, CNA #1 stated, we document it in PCC (point click care). On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Activities of Daily Living policy revealed in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal care and oral hygiene. Provision or resident refusal of activities of daily living/personal care shall be documented in the clinical record. No further information was provided prior to exit. 3. For Resident #32 (R32), the facility staff failed to provide ADL (activities of daily living) care to a dependent resident on multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/8/24, the resident scored 15 out of 15 on the BIMS (brief assessment for mental status), indicating R32 was cognitively intact for making daily decisions. Section GG documented R32 requiring supervision or touching assistance for toileting hygiene and being frequently incontinent of bowel and bladder. On 8/26/24 at 4:40 p.m., an interview was conducted with R32 in their room. R32 was observed sitting in a wheelchair in their room. R32 stated that they were often left wet and not changed in a timely manner. R32 stated that some of the CNA (certified nursing assistant) staff tell them that they should be able to get the bathroom and should not be incontinent but they could not help it. R32 stated that they could not walk since they had recently had COVID-19 and was working with therapy to get their strength back. R32 stated that they felt that the CNA staff did not believe that they could not help being incontinent and made them wait to be changed on purpose but could not name any specific staff. The comprehensive care plan for R32 documented in part, [Name of R32] has bladder/bowel incontinence. Date Initiated: 09/06/2022. Revision on: 06/02/2023. Review of the ADL documentation report for R32 dated 6/1/24-6/30/24 failed to evidence assistance with toileting provided on day shift on 6/2/24, 6/3/24, evening shift on 6/11/24 and night shift on 6/3/24, 6/9/24, 6/12/24, 6/19/24, 6/23/24 and 6/27/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . Review of the ADL documentation report for R32 dated 7/1/24-7/31/24 failed to evidence assistance with toileting on evening shift on 7/4/24 and night shift on 7/4/24, 7/6/24, 7/9/24, 7/11/24, 7/12/24, 7/15/24, 7/17/24, 7/19/24, 7/24/24, 7/28/24 and 7/30/24. Review of the ADL documentation report for R32 dated 8/1/24-8/30/24 failed to evidence assistance with toileting on day shift on 8/5/24, 8/7/24-8/12/24, 8/14/24, 8/15/24, 8/18/24, and 8/26/24. If further failed to evidence assistance with toileting on evening shift 8/6/24, 8/16/24, 8/18/24, and 8/22/24, and on night shift on 8/4/24, 8/11/24, 8/12/24, 8/17/24, 8/19/24, 8/21/24, and 8/27/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . Review of the clinical record failed to evidence documentation of R32 being out of the facility or refusing care on the dates listed above. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA #7. CNA #7 stated that residents were rounded on every two hours to check for needs such as incontinence care, water, pain and turning and repositioning. She stated that the care that they provided to the resident was evidenced by their documentation in the ADLs each shift in the computer under toileting. On 8/30/24 at 10:00 a.m., an interview was conducted with CNA #8. CNA #8 stated that if NA was documented in the ADLs it meant not applicable and usually the resident was out at an appointment or not in the building at that time. She stated that it would be documented that the resident was out of the building in the medical record. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. 4. For Resident #67 (R67), the facility staff failed to provide ADL (activities of daily living) care to a dependent resident on 9/30/23 and multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, the resident scored seven out of 15 on the BIMS (brief assessment for mental status), indicating R67 was severely impaired for making daily decisions. Section GG documented R67 being dependent on staff for toileting, bathing, dressing, bed mobility, transfers, and personal hygiene. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under hospice care. R67's family member stated that they had multiple concerns regarding the care that was received at the facility and stated that on 9/30/23, R67 had been left sitting up in the wheelchair all night long after returning to the facility from a leave with family. She stated that R67 had asked the staff to put them back to bed and they had not done it and the staff had told them that it was because R67 was refusing to go to bed. She stated that R67 had been left sitting in the wheelchair in soiled clothing and not assisted back to bed the entire night and not cleaned up until the day shift staff got there the next day. R67's family member further stated that the staff did not come in to turn and reposition them every two hours and left the resident soiled for extended periods of time. She stated that R67 could not turn themselves and relied on the staff to come in to turn them, but she often found him lying in one position the entire time she was there to visit. She stated that since hospice had come on board that they had been providing most of the care to R67. The comprehensive care plan for R67 documented in part, [Name of R67] has an ADL self-care performance deficit AEB (as evidenced by) spinal stenosis, osteoarthritis, & pain. Date Initiated: 02/01/2024. Revision on: 02/01/2024. Under Interventions it documented in part, .Physical assist as needed with ADLs. Date Initiated: 05/30/2023. Revision on: 06/14/2023 . Review of the ADL documentation report for R67 dated 9/1/23-9/30/23 failed to evidence any ADL care provided, transfer assistance provided, refusal of care or behaviors displayed by R67 on the night shift (11:00 p.m. to 7:00 a.m.) shift for 9/30/23. Review of the ADL documentation report for R67 dated 6/1/24-6/30/24 failed to evidence assistance with bed mobility provided on day shift on 6/14/24 and 6/30/24, and on evening shift on 6/14/24, 6/17/24, 6/21/24 and 6/23/24. It further failed to evidence assistance with bed mobility on night shift on 6/1/24, 6/4/24, 6/7/24, 6/8/214, 6/11/24, 6/15/24, 6/19/24, 6/22/24, 6/28/24 and 6/30/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . Review of the ADL documentation report for R67 dated 7/1/24-7/31/24 failed to evidence assistance with bed mobility provided on day shift on 7/4/24, and on night shift on 7/2-7/8/24, 7/10-7/22/24, 7/24-7/27/24, 7/30/24 and 7/31/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . Review of the ADL documentation report for R67 dated 8/1/24-8/30/24 failed to evidence assistance with bed mobility provided on day shift on 8/17/24, and on evening shift on 8/17/24 and 8/21/24. If further failed to evidence assistance with bed mobility on night shift on 8/2/24, 8/4/24, 8/10-8/12/24, 8/17/24, 8/19/24, 8/21/24, 8/23/24, and 8/28/24. The documentation areas were either blank or documented NA. The report key documented NA-Not Applicable . The progress notes for R67 documented in part, - 09/29/2023 07:50 Note Text: Resident went OOF (out of facility) this morning as per his routine, facility aware. Resident had morning meds w/O difficulty before leaving. - 09/30/2023 22:42 (10:42 p.m.) Note Text: Aide offered to put resident down after writer finished medication pass, refused 3x to go to bed and stated wanted to sit on commode for an hour before bed advised that due to pressure sore risks and skin integrity complications that this was strongly advised against. Brief on and intact, offered to help change brief, denied assistance. Passed in report that resident refused help offered to him. The progress notes for R67 failed to evidence documentation of any further attempts to provide care to R67 during the night shift on 9/30/2023 or refusal of care. Review of the clinical record failed to evidence documentation of R67 being out of the facility or refusing care on the dates listed above. On 8/28/24 at approximately 8:45 a.m., ASM (administrative staff member) #1, the administrator stated that the RN (registered nurse) who wrote the progress note on 9/30/23 and the CNA (certified nursing assistant) who worked on the unit that R67 resided on 9/30/23, no longer worked at the facility. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA #7. CNA #7 stated that residents were rounded on every two hours to check for needs such as incontinence care, water, pain and turning and repositioning. She stated that the care that they provided to the resident was evidenced by their documentation in the ADLs each shift in the computer. She stated that she was not aware of any residents who would be left up in their wheelchair all night unless that was what they requested or if it was a behavior and it would be reported to the nurse and documented. She stated that when she worked with R67, they were complaint with care. She stated that R67 required staff to turn and reposition them and they documented the care provided under bed mobility. On 8/30/24 at 10:00 a.m., an interview was conducted with CNA #8. CNA #8 stated that when a resident refused care, they let the nurse know and returned to the resident later with the nurse to re-attempt the care. She stated that if the resident still refused the care it was documented in the medical record in the ADLs and the nurse also documented the refusal and reported it. She stated that if NA was documented in the ADLs it meant not applicable and usually the resident was out at an appointment or not in the building at that time and the nurses documented where the resident was in their notes. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN (registered nurse) #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for dependent residents for four of 50 residents in the survey sample, Residents #96, #108, #32, and #67. The findings include: 1. For Resident #96 (R96), the facility staff failed to clean him and his bed linens after he vomited. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated that last Saturday, 8/24/24, he woke up very early in the morning, around 6:00 a.m. LPN (licensed practical nurse) #4 was at his bedside administering a tube feeding. As LPN #4 walked away from his bed towards the bathroom, he experienced severe nausea. He called out to the nurse, then vomited a large amount. He stated he caught some of the emesis in a basin, but much of it landed on his clothing and bed linens. He stated a CNA (certified nursing assistant) came in the room, but he could not remember the CNA's name. He stated the CNA placed a clean towel over his chest, and walked out of the room, along with LPN #4. He stated no one came in to clean him up and change his bed linens until after 9:00 a.m. that morning. A review of R96's clinical record revealed no evidence of this incident. On 8/29/24 at 7:30 a.m., LPN #4 were interviewed. She stated she remembered the morning that R96 vomited. She had worked the night shift, and was providing the resident's early morning tube feeding. She stated within about five minutes of finishing administering his tube feeding, he vomited it all back up. She stated the CNA working with her put a towel across the resident's chest, and walked out the door with her. She stated: I thought she was going to get supplies to clean him up. The CNA in question was not available for interview during the survey. A review of R96's care plan dated 7/12/24 revealed, in part: [R96] has an ADL self-care deficit .Physical assist as needed. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. A review of the facility policy, Activities of Daily Living, revealed, in part: Each resident shall be given proper daily personal attention and care, including skin, nails, hair, and oral hygiene, in addition to any specific care ordered by the attending physician .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .Hygiene (bathing, dressing, grooming, and oral care) .Residents will be assisted with dressing and grooming as appropriate. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility failed to administer anticoagulation therapy as ordered for Resident #113. Resident #113 was admitted to the facility on [DATE] with diagnosis that included fractures and hypertension. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and independent for eating. A review of the baseline care plan dated 8/3/23 revealed, FOCUS: Resident has actual impairment to skin integrity related to Surgical Wound. INTERVENTIONS: Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. There is no evidence of the baseline care plan including any focus or interventions related to anticoagulation therapy or monitoring. A review of the physician order dates 7/21/23 revealed Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML. Inject 0.4 ml subcutaneously every 12 hours. A review of the July and August 2023 MAR (medication administration record) reveals scheduled time for Enoxaparin injection scheduled for 12:00 AM and 12:00 PM. Review of the administration times reveals the following delays in administration of Enoxaparin: 7/22- 3:28 AM and 1:30 PM, 7/24-1:30 PM, 7/31-1:21 AM and 1:37 PM, 8/2-5:00 AM and 1:29 PM, 8/5-2:42 PM, 8/6-1:24 PM, 08/7-1:24 PM, 8/8-2:54 PM, 8/10-1:15 PM, 8/11-3:26 AM and 1:10 PM and 8/12-1:50 AM and 4:17 PM. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked where the evidence of anticoagulation injections would be located, LPN #2 stated, it would be on the MAR. When asked if the physician orders for anticoagulation medication administration were not followed, were professional standards followed, LPN #2 stated, no, they would not be followed. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Medication Administration policy revealed in part, This policy establishes the guidelines for the safe and effective administration of medications at Hill Valley Healthcare. All medications administered within the facility are subject to these guidelines. The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed at the following stages during medication administration. No further information was provided prior to exit. 5. The facility staff failed to provide respiratory care services per physician orders for Resident #108. Resident #108 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CAD (coronary artery disease), COPD (chronic obstructive respiratory disease), hyponatremia and asthma. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 5/20/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan with a revision date of 5/16/24, revealed, FOCUS: The resident has altered respiratory status/difficulty breathing related to COPD, acute/chronic respiratory failure with hypoxia. INTERVENTIONS: Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing and nasal flaring. A review of the physician orders dated 5/15/24 revealed, Respiratory Assessment: Assess lung sounds, respiratory rate, pulse Ox and report any abnormalities to physician (document abnormalities in nursing note). Educate resident on importance of reporting respiratory changes. every shift for 14 Days. A review of the May 2024 TAR (treatment administration record) revealed missing documentation for the respiratory assessment on day shift: 5/16 and 5/18 as well as night shift on 5/17. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked where the evidence of respiratory assessments would be located, LPN #2 stated, it would be on the TAR. When asked if the physician orders for respiratory care were not followed, were professional standards followed, LPN #2 stated, no, they would not be followed. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's CPAP-BIPAP guidance policy revealed in part, The facility will implement procedures to ensure that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the resident's choice. No further information was provided prior to exit. 3. For Resident #114 (R114), the facility staff failed to provide care and services to a non-pressure related skin condition as ordered on multiple dates in August 2023, September 2023 and October 2023. The physician orders for R114 documented in part, - Nystatin External Cream 100000 UNIT/GM (Nystatin (Topical)) Apply to affected areas topically every day and evening shift for redness until healed. Order Date: 06/13/2024. Review of the eTAR (electronic treatment administration record) for R114 dated 8/1/23-8/31/23 failed to evidence the Nystatin treatment completed on day shift on 8/2/23-8/7/23, 8/12/23-8/14/23, 8/19/23-8/21/23, 8/26/23-8/28/23 and 8/31/23. It further failed to evidence the Nystatin treatment completed on evening shift on 8/1/23-8/2/23, 8/5/23-8/6/23, 8/12/23-8/13/23, 8/19/23, 8/27/23 and 8/31/23. Review of the eTAR for R114 dated 9/1/23-9/30/23 failed to evidence the Nystatin treatment completed on day shift on 9/1/23-9/2/23, 9/4/23, 9/9/23, 9/11/23-9/12/23, 9/16/23-9/18/23, and 9/18/23. It further failed to evidence the Nystatin treatment completed on evening shift on 9/1/23-9/2/23, 9/9/23, 9/16/23-9/18/23, 9/21/23, and 9/23/23. Review of the eTAR for R114 dated 10/1/23-10/31/23 failed to evidence the Nystatin treatment completed on day shift on 10/7/23 and 10/20/23. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that non-pressure treatments were completed by the floor nurses assigned each day and they were evidenced as completed by the staff signing them off on the eTAR. On 8/29/24 at 12:40 p.m., an interview was conducted with RN (registered nurse) #5. RN #5 stated that the nursing staff provided care to any yeast rashes as ordered by the physician and evidenced the treatment as done by signing it off on the eTAR. The facility provided policy, Non-Pressure Injury/Ulcer Management documented in part, .Treatments, including preventative interventions, will be documented in the resident's medical record . On 8/30/24 at approximately 11:39 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #9, the regional director of clinical operations, and ASM #8, the regional director of operations were made aware of the concern. No further information was obtained prior to exit. 6. For Resident #112 (R112), the facility staff failed obtain orders to check the resident's blood sugar and to administer insulin upon admission. A review of R112's hospital Discharge summary dated [DATE] revealed, in part: Discharge Diagnoses .Diabetes mellitus type 2 .continue current regimen .Medications Inpatient .Insulin lispro .with meals and at bedtime. A review of R112's clinical record revealed he was admitted to the facility on [DATE]. This review revealed the following progress notes: 8/26/23 at 7:00 p.m. Resident's spouse voiced concerns he didn't have accucheck (test for blood glucose levels) orders nor insulin orders, and that he was [name of medication to treat diabetes] at home .at hospital .he was on insulin. MD (medical doctor) on call made aware and insulin orders given. A review of R112's MAR (medication administration record) revealed he received a one-time dose of Humalog Lispro (short-acting insulin) 15 units on 8/26/23 at 7:00 p.m. This review failed to reveal any blood sugar checks or insulin administration between his admission on [DATE] at 8:00 p.m. and 8/27/23 at 7:00 p.m. On 8/29/24 at 9:40 a.m., ASM (administrative staff member) #4, a nurse practitioner, was interviewed. She stated if a resident has been on accuchecks and insulin in the hospital, she would initially order sliding scale insulin before meals and at bedtime. Once the resident's insulin needs have been established, she stated she attempts to get the resident on scheduled insulin rather than a sliding scale. She added: If they are on something at the hospital, they should be on something here. On 8/29/24 at 1:07 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated if a resident is discharged with orders for insulin, those orders should be called in to the provider for approval. She stated the whole of the resident's discharge records should be reviewed for accurate medication reconciliation. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 7.a. For Resident #117 (R117), the facility staff failed to obtain orders to check the resident's blood sugar and to administer insulin upon admission. A review of R117's hospital Discharge summary dated [DATE] revealed, in part: Primary Discharge Diagnosis .Diabetes mellitus .Diabetes mellitus with hyperglycemia (high blood sugar) .Continue glycemic protocol .Consider increasing sliding scale. A review of R117's clinical record revealed the resident was admitted to the facility on [DATE] at approximately 10:00 p.m. This review revealed the following progress notes: 1/28/23 Note text 1903 (7:03 p.m.) .Notified by RP (responsible party) resident is on scheduled insulin and accuchecks (blood sugar checks) four times a day at home. NP (nurse practitioner) made aware and new orders received and RP made aware. This reviewed revealed the provider gave orders for accuchecks and insulin on 1/28/23 at 7:26 p.m. These were the first orders for accuchecks and insulin since the resident's admission on [DATE]. On 8/29/24 at 9:40 a.m., ASM (administrative staff member) #4, a nurse practitioner, was interviewed. She stated if a resident has been on accuchecks and insulin in the hospital, she would initially order sliding scale insulin before meals and at bedtime. Once the resident's insulin needs have been established, she stated she attempts to get the resident on scheduled insulin rather than a sliding scale. She added: If they are on something at the hospital, they should be on something here. On 8/29/24 at 1:07 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated if a resident is discharged with orders for insulin, those orders should be called in to the provider for approval. She stated the whole of the resident's discharge records should be reviewed for accurate medication reconciliation. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 7.b. For Resident #117 (R117), the facility staff failed to assess a surgical wound. A review of R117's hospital Discharge summary dated [DATE] revealed, in part: Staples from knee to be removed 1/30/23. Cover with dry dressing for 2 days then discontinue the dressing. Follow up with [name of orthopedic surgeon] 3/1/23. A review of R117's clinical record revealed no evidence of assessment of R117's knee surgical wound between her admission on [DATE] and the removal of the staples on 1/30/23. On 8/29/24 at 1:07 p.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated if a resident is admitted with a surgical wound, she would look for orders for wound care on the resident's hospital discharge summary. She stated, If there are orders there, we need to follow them. She stated the facility staff are responsible for assessing the surgical site prior to removal of any stitches or staples. She stated the assessment needs to include skin integrity and any signs or symptoms of infection. She stated if there are no orders on the discharge summary, the wound nurse should be contacted for orders. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 8. For Resident #53, the facility staff failed to administer medications per physician's order. A review of the clinical record revealed a physician's order dated 11/16/22 for Gabapentin (1) 600 mg (milligrams) one tab twice daily at 1:00 PM and 6:00 PM for disorders of the peripheral nervous system; and a physician's order dated 11/16/22 for Gabapentin 600 mg 1 and a half tab twice daily at 8:00 AM and 9:00 PM. A review of the December 2023 MAR (Medication Administration Record) revealed the following: The order for 600 mg 1 tab twice daily was not administered on 12/17/23 at 6:00 PM as evidence by no documentation for that administration date and time; and the order for 600 mg 1 and a half tab twice daily was not administered on 12/16/23 at 9:00 PM and 12/21/23 at 8:00 AM, as evidenced by no documentation for those administration dates and times. Further review of the clinical record revealed a physician's order dated 11/4/23 for Magnesium (2) 400 mg twice daily for Rhabdomyolysis. A review of the December 2023 MAR revealed that this medication was not administered on 12/17/23 at 5:00 PM as evidenced by no documentation for that administration date and time. On 8/30/24 at 10:50 AM, an interview was conducted with LPN #1 (Licensed Practical Nurse). She stated that if it was not marked on the MAR then the doses were missed. She stated that the MAR is how it is evidenced that the medication was given. The facility policy, Medication Administration was reviewed. This policy documented, 7. After administering the medication, .document the administration in the MAR/TAR 9. Document any refusal of medication on the MAR/TAR On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Gabapentin is used for seizures, postherpetic neuralgia, and restless leg syndrome. Information obtained from https://medlineplus.gov/druginfo/meds/a694007.html 2. Magnesium is used to treat low magnesium levels Information obtained from https://medlineplus.gov/druginfo/meds/a601074.html Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of well-being for eight of 50 residents in the survey sample, Residents #157, #34, #114, #113, #108, #112, #117 and #53. The findings include: 1.a. For Resident #157 (R157), the facility staff failed to obtain blood sugars as ordered by the physician. During an interview with R157 on 8/26/24 at 3:55 p.m. the resident stated that the nurses come in to do her blood sugar either while she is eating or after she finishes eating. Then they try to give her insulin and the blood sugar is high due to eating. The physician order dated 8/9/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals and at bedtime for diabetes. D/C (discontinue date) 8/18/24. The blood sugars are scheduled for 7:00 a.m., 11:00 a.m., 4:00 p.m. and 9:00 p.m. The physician order dated 8/12/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals for diabetes. The blood suugars are scheduled for 6:30 a.m., 11:00 a.m. and 4:00 p.m. The physician order dated 8/23/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451 - 500 = 14 units. subcutaneously before meals for diabetes. The blood sugars are scheduled for 6:30 a.m., 11:00 a.m. and 4:00 p.m. The documented mealtimes for the facility are: Breakfast - 7:30 a.m. Lunch - 12:00 p.m. Dinner - 5:00 p.m. The August 2024 MAR (medication administration record) documented the above orders. On the following dates and times, the blood sugars were taken during or after the meals: 8/10/24 at 5:48 p.m. - scheduled for 4:00 p.m. 8/11/24 at 5:50 p.m. - scheduled for 4:00 p.m. 8/12/24 at 9:20 a.m. - scheduled for 7:00 a.m. 8/12/24 at 5:39 p.m. - scheduled for 4:00 p.m. 8/13/24 at 12:02 p.m. - scheduled for 11:00 a.m. 8/13/24 at 6:41 p.m. - scheduled for 4:00 p.m. 8/21/24 at 6:25 p.m. - scheduled for 4:00 p.m. 8/23/24 at 12:48 p.m. - scheduled for 11:00 a.m. 8/24/24 at 6:60 p.m. - scheduled for 4:00 p.m. 8/26/24 at 10:21 p.m. - scheduled for 4:00 p.m. 8/27/24 at 1:10 p.m. - scheduled for 11:00 a.m. 8/28/24 at 1:41 p.m. - scheduled for 11:00 a.m. The comprehensive care plan dated 8/21/24, documented in part, Focus: (R157) has Diabetes Mellitus. The Interventionsdocumented in part, Fasting Serum Blood Sugar as ordered by doctor. An interview was conducted with ASM (administrative staff member) #4, the nurse practitioner, on 8/29/24 at 9:54 a.m. When asked why a resident is on sliding scale insulin, ASM #4 stated, to help cover them when the blood sugars are higher when the resident has eaten sugary snacks. ASM #4 was asked what times they are normally ordered, ASM #4 stated before meals and at bedtime. When asked what would happen if the blood sugar was taken after the resident ate their meal, ASM #4 stated, it depends, if they've only eaten five bites or so, then nothing, but if they've eaten their whole meal, say 30 minutes to an hour later, it would elevate the blood sugar, thus giving them too much insulin and the risk of their blood sugar going too low. An interview was conducted with RN (registered nurse) #5 on 8/29/24 at 12:40 p.m. When asked when blood sugars are taken for a resident receiving sliding scale insulin, RN #5 stated, before meals and at bedtime. RN #5 was asked if she would take a blood sugar if the resident has started to eat their meal, RN #5 stated, no. When asked the purpose of taking the blood sugar before meals, RN #5 stated the meal would make the blood sugar go up. RN #5 was asked if dinner is at 5:00 p.m. is it appropriate to take the blood sugar at 6:30 p.m., RN #5 stated no, the purpose is to take it before the meal is eaten. The facility policy, Medication Administration, documented in part, 6. Obtain and document any necessary vital signs or monitoring parameters before administration. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 1.b. For Resident #157, the facility staff failed to administer insulin as ordered by the physician. The physician order dated 8/23/24 documented, Levemir Flex Pen Subcutaneous Solution Pen- Injector 100 UNIT/ML; Inject 50 units subcutaneously at bedtime for DM (diabetes mellitus). The August 2024 MAR documented the above order. On 8/24/24, there was a blank on the space for the medication to be documented as administered. Review of the nurse's notes failed to evidence documentation of a reason why the medication was not given. The comprehensive care plan dated 8/21/24, documented in part, Focus: (R157) has Diabetes Mellitus. The Interventionsdocumented in part, Diabetes medication as ordered by doctor. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked how she evidenced that she's given a medication, RN #5 stated she documents in on the electronic MAR. The facility policy, Medication Administratiomn documented in part, 7. After administering the medication, return multi-dose containers to the cart and document the administration in the MAR/TAR, including controlled substances where applicable. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations, and ASM #9, the regional director of clinical services were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was obtained prior to exit. 1.c. For Resident #157, the facility staff delayed in starting an antibiotic for the treatment of an infection and the 8:00 p.m. dose was not documented as having been given on 8/24/24. The physician order dated 8/22/24 at 3:42 p.m. documented, Clindamycin HCL (hydrochloride)(an antibiotic); 150 MG (milligrams) give 3 capsules by mouth three times a day for abscess to buttocks for 10 days. The medication was scheduled for 7:00 a.m., 11:00 a.m. and 8:00 p.m. The August 2024 MAR documented the above order. The first dose was documented as having been given on 8/23/24 at 7:00 a.m. On 8/24/24 at the scheduled 8:00 p.m. dose, nothing was documented in the space. Review of the contents of the facility, onsite, pharmacy system, documented the Clindamycin 150 mg was available in the system. The comprehensive care plan dated, 8/23/24, documented in part, Focus: (R157) is on antibiotic therapy r/t (related to) abscess to right buttock. The Interventions documented in part, Administer ANTIBIOTIC medications as ordered by physician. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked if a physician order is written on 8/22/24 for an antibiotic, when would the antibiotic be started, RN #5 stated, on the 22nd, if it was started on the 23rd, it would be a delay in treatment. When asked how she evidenced that she's given a medication, RN #5 stated she documents in on the electronic MAR. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #8, the regional director of operations, and ASM #9, the regional director of clinical services were made aware of the above concern on 8/30/24 at 11:00 a.m. No further information was obtained prior to exit. 2. For Resident #34 (R34), the facility staff failed to administer Xarelto (used to prevent blood clots). An interview was conducted with R34 on 8/26/24 at 3:45 p.m. The resident stated that she had missed several doses of her Xarelto. The physician order dated 7/31/23, documented, Xarelto Oral Tablet 20 MG (Rivaroxaban); Give 1 tablet by mouth in the evening for prophylactic related to personal history of other venous thrombosis and embolism; atherosclerosis of aorta. The August MAR (medication administration record) documented the above order. On 8/21/24 and 8/22/24, a 9 was documented in the administration box on the MAR. A 9 indicated, Other/See Progress Note. Review of the progress notes dated 8/21/24 and 8/22/24, documented, Not on hand. for both days. Review of the contents of the facility, onsite, pharmacy system, documented the Xarelto 10 mg tablets were available in the system. The comprehensive care plan dated 8/18/23 documented in part. Focus: The resident is on anticoagulant therapy. The Interventions documented in part, Administer ANTOCOAGULANT medications as ordered by physician. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked what she does if a medication is not on the medication cart at the scheduled time for administration, RN #5 stated she would first call the pharmacy. RN #5 was asked if the facility had a backup system for medications, RN#5 stated, yes, I would check there especially if the pharmacy were not open. When asked if the medication is not in the backup system, does she have to notify anyone, RN #5 stated, yes, we have to notify the provider and the responsible party for the resident. The facility policy, Unavailable Medications, documented in part, Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident .The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.The facility failed to evidence wound treatment for Resident #116. Resident #116 was admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, sacral ulcer and ASCVD (atherosclerotic cardiovascular disease). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/6/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 9/14/22 revealed, FOCUS: Resident has a skin tear to her right shin. INTERVENTIONS: Treatment as ordered. A review of the physician orders dated 12/24/22 revealed, Cleanse wound to right lower leg and Left forearm with wound cleanser, apply xeroform gauze to wound, cover with kerlix, secure with tape. One time a day for skin tear. A review of the December 2022, January 2023 and February 2023 MAR (medication administration record) revealed missing evidence of wound treatments provided on the following dates: 12/28/22, 12/30/22, 12/31/22, 1/2/23, 1/3/23, 1/13/23, 1/16/23, 1/21/23 1/24/23, 1/31/23, and 2/7/23. An interview was conducted on 8/29/24 at 2:20 PM with LPN (licensed practical nurse) #3. When asked where evidence of wound treatment would be located, LPN #3 stated, it would be on the TAR. When asked if there is no evidence that is has been completed, has wound care been performed, LPN #3 stated, no, it has not been. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Non-Pressure Injury/Ulcer Management policy revealed in part, Treatments will be ordered by the physician/practitioner. Treatments including preventive interventions will be documented in the resident's medical record. No further information was provided prior to exit. Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of pressure injuries for three of 50 residents in the survey sample, Residents #67, #111 and #116. The findings include: 1. For Resident #67 (R67), the facility staff failed to provide treatment as ordered to a pressure injury (1) on multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, the resident scored seven out of 15 on the BIMS (brief assessment for mental status), indicating R67 was severely impaired for making daily decisions. The assessment documented R67 having one Stage II pressure injury that was not present on admission. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under hospice care. R67's family member stated that they had multiple concerns regarding the care that was received at the facility. R67's family member stated that the staff did not come in to turn and reposition every two hours and left the resident soiled for extended periods of time. She stated that R67 could not turn themselves and relied on the staff to come in to turn them, but she often found him lying in one position the entire time she was there to visit. She stated that since hospice had come on board that they had been providing most of the care to R67. She stated that the staff were supposed to put a cream on R67's backside for skin breakdown but they did not do it like they were supposed to. The comprehensive care plan for R67 documented in part, [Name of R67] has potential for impairment to skin integrity r/t impaired mobility. Date Initiated: 08/18/2023. Revision on: 08/26/2024. The physician orders for R67 documented in part, - Apply zinc cream to lower back every shift for rash every shift. Order Date: 07/21/2024. - Skin protectant to left heel twice daily two times a day for skin protectant. Order Date: 06/03/2024. - Zinc to bilateral buttock and perianal area q shift and prn as needed. Order Date: 07/02/2024. - Greers goo perianal and buttock daily and PRN every evening shift for MASD (moisture associated skin damage). Start Date: 06/7/2024. - Clean right and left buttock with wound cleanser, skin prep periwound and apply medihoney and cover with foam dressing QD (every day) and prn every day shift. Start Date: 06/07/2024. - Cleanse right buttock with wound cleanse, apply medihoney and dry dressing daily and prn every day shift. Start Date: 07/02/2024. Review of the eTAR (electronic treatment administration record) for R67 dated 6/1/24-6/31/24 failed to evidence the Greers goo treatment administered on 6/7/24-6/11/24 and 6/24/24. It further failed to evidence the treatment to the left buttock administered on 6/9/24. Review of the eTAR for R67 dated 7/1/24-7/30/24 failed to evidence the zinc to the bilateral buttocks and perianal area on day shift 7/3/24 and evening shift on 7/5/24. It further failed to evidence treatment to the right buttock medihoney treatment completed on 7/4/24, 7/13/24, and 7/14/24. Review of the eTAR for R67 dated 8/1/24-8/31/24 failed to evidence the zinc to the bilateral buttocks and perianal area on day shift on 8/12/24 and 8/17/24, on evening shift on 8/13/24 and 8/15/24 and on night shift on 8/9/24 and 8/24/24. It further failed to evidence the zinc cream to the lower back administered on day shift 8/12/24 and 8/17/24, on evening shift 8/13/24 and 8/15/24 and on night shift 8/9/24 and 8/24/24. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the wound nurse was there during the week and when she was not there the floor nurses were expected to complete the wound care treatments. She stated that the wound care was evidenced by the nurse writing the time, date, and initials on the dressing and signing them off as completed on the eTAR. On 8/28/24 at 11:39 a.m., an interview was conducted with RN (registered nurse) #3, wound care. RN #3 stated that they had been at the facility for about two months and prior to them starting, the floor nurses were doing the wound care treatments. She stated that wound care was evidenced as done by the nurse signing off on the eTAR and if not completed or the resident was not available for the wound care it would be documented on the eTAR and the provider would be made aware. The facility provided policy, Non-Pressure Injury/Ulcer Management documented in part, .Treatments, including preventative interventions, will be documented in the resident's medical record . On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website:https://medlineplus.gov/ency/patientinstructions/000740.htm. 2. For Resident #111 (R111), the facility staff failed to provide treatment to a pressure injury (1) as ordered on multiple dates from 9/1/23-12/31/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/2/24, the resident was assessed as having one Stage 2 pressure injury that was not present on admission. The comprehensive care plan for R111 documented in part, [Name of R111] has an unstageable pressure ulcer (see wound nurse note 3/24/2023) on her sacrum r/t decreased mobility, incontinence. Date Initiated: 05/05/2023. Revision on: 11/02/2023. Under Interventions it documented in part, Apply treatments as ordered and monitor for effectiveness. Date Initiated: 05/05/2023. Revision on: 11/02/2023. The progress notes for R111 documented in part, 6/7/2023 16:18 (4:18 p.m.) Weekly wound assessment completed. Unstageable Pressure Ulcer to other: Sacral. Overall impression: new wound- first observation. See wound evaluation weekly for additional details . The physician orders for R111 documented in part, Clean area to sacrum with normal saline or soap and water apply barrier cream cover with foam dressing qday (every day) and prn (as needed) when soiled. every day shift for assessment. Review of the eTAR (electronic treatment administration record) for R111 dated 9/1/23-9/30/23 failed to evidence a treatment completed as ordered to the sacral area on 9/4/23, 9/9/23, 9/11/23, 9/15-9/18/23, 9/21/23, 9/23/23, and 9/28/23. Review of the eTAR for R111 dated 10/1/23-10/31/23 failed to evidence a treatment completed as ordered to the sacral area on 10/6/23, 10/7/23, and 10/24/23. Review of the eTAR for R111 dated 11/1/23-11/30/23 failed to evidence a treatment completed as ordered to the sacral area on 11/17/23. Review of the eTAR for R111 dated 12/1/23-12/31/23 failed to evidence a treatment completed as ordered to the sacral area on 12/1/23, 12/7/23, 12/16/23, 12/17/23, 12/19/23, and 12/22-12/24/23. On 8/28/24 at 9:27 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the wound nurse was there during the week and when she was not there the floor nurses were expected to complete the wound care treatments. She stated that the wound care was evidenced by the nurse writing the time, date, and initials on the dressing and signing them off as completed on the eTAR. On 8/28/24 at 11:39 a.m., an interview was conducted with RN (registered nurse) #3, wound care. RN #3 stated that they had been at the facility for about two months and prior to them starting the floor nurses were doing the wound care treatments. She stated that wound care was evidenced as done by the nurse signing off on the eTAR and if not completed or the resident was not available for the wound care it would be documented on the eTAR and the provider would be made aware. On 8/29/24 at approximately 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN (registered nurse) #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for 2 of 50 residents, Resident #108 and #407. The findings include: 1. The facility staff failed to provide respiratory care services per physician orders for Resident #108. Resident #108 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CAD (coronary artery disease), COPD (chronic obstructive respiratory disease), hyponatremia and asthma. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 5/20/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan with a revision date of 5/16/24, revealed, FOCUS: The resident has altered respiratory status/difficulty breathing related to COPD, acute/chronic respiratory failure with hypoxia. INTERVENTIONS: Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing and nasal flaring. A review of the physician orders dated 5/15/24 revealed, Respiratory Assessment: Assess lung sounds, respiratory rate, pulse Ox and report any abnormalities to physician (document abnormalities in nursing note). Educate resident on importance of reporting respiratory changes. every shift for 14 Days. A review of the May 2024 TAR (treatment administration record) revealed missing documentation for the respiratory assessment on day shift: 5/16 and 5/18 as well as night shift on 5/17. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked where the evidence of respiratory assessments would be located, LPN #2 stated, it would be on the TAR. When asked if the physician orders for respiratory care were not followed, were professional standards followed, LPN #2 stated, no, they would not be followed. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's CPAP-BIPAP guidance policy revealed in part, The facility will implement procedures to ensure that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the resident's choice. No further information was provided prior to exit. 2. The facility staff failed to provide respiratory care services per physician orders for Resident #407. Resident #407 was admitted to the facility on [DATE] with diagnosis that included fracture right lower leg, OSA (obstructive sleep apnea), asthma and paroxysmal atrial fibrillation. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 8/16/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being max assist for mobility/transfers, dressing, hygiene toileting and independent for eating. Section O-Special Treatments and Procedures coded the resident as non-invasive Bipap-yes. A review of the baseline care plan dated 8/23/24 revealed, FOCUS: Resident has actual impairment to skin integrity related to Surgical Wound. INTERVENTIONS: Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. A review of the physician order dates 8/13/24 revealed CPAP mask cleaning every Morning after removing one time a day. A review of the August 2024 Nursing Task Administration Record revealed no evidence of the CPAP being cleaned from 5/13/24 through 5/27/24. An interview was conducted on 8/28/24 at 2:35 PM with Resident #407. When asked who was cleaning his mask, Resident #407 stated, no one. I usually clean it, but being in this wheelchair with broken bone, I have not cleaned it. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked where the evidence of cleaning CPAP mask would be located, LPN #2 stated, it would be on the TAR. When asked if the physician orders for respiratory care were not followed, were professional standards followed, LPN #2 stated, no, they would not be followed. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's CPAP-BIPAP guidance policy revealed in part, The facility will implement procedures to ensure that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the resident's choice. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 50 residents in the survey sample, Residents #96 and #72. The findings include: 1. For Resident #96 (R96), the facility staff failed to assess the resident's need for an increase in his scheduled pain medication. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated he was concerned about having to ask so frequently for pain medications. He stated sometimes the staff was too busy to bring the medications in a timely manner, and he did not feel he should have to ask for pain medication so many times during the day and night. A review of R96's clinical record revealed the following orders: 7/31/24 Oxycodone (an opioid pain medication) Oral Tablet 10 mg (milligrams) .Give 2 tablets by mouth every 4 hours as needed for breakthrough pain related to multiple sclerosis. 8/15/24 Oxycodone Oral Tablet 10 mg .Give 2 tablets every 4 hours as needed for breakthrough pain. A review of R96's August 2024 MAR (medication administration record) revealed he received a total of 51 as needed doses of Oxycodone between 8/1/24 and 8/28/24. The review revealed pain level assessments prior to the administration of the Oxycodone to range between 6 and 9. The as needed Oxycodone was administered over the entire range of days, evenings, and nights. On 8/28/24 at 12:38 p.m., ASM (administrative staff member) #4, the attending physician, was interviewed. When asked his role in monitoring prn (as needed) pain medication for residents, he stated a resident's frequent usage of a prn pain medication could be mentioned either by the resident or by the nurse. He stated: Certainly if the prns are being given around the clock, or the resident is frequently requesting a dose, something needs to be adjusted. He stated the resident's maintenance (scheduled) pain medication may need to be increased. He added this decision should take into account the reason for the pain, with the goal of getting the resident off of narcotic pain medications as soon as possible. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated when a resident requests a prn pain medication, the nurses try an alternative to the medication first. This could include repositioning or a warm/cold compress, depending on the nature of the pain and the resident's orders. She stated if the alternative interventions are unsuccessful in relieving the resident's pain, the nurse should administer the as needed medication. She stated when the nursing staff notices a trend of the resident being in constant pain, the nurses talk to the nurse practitioner to see if something needs to be scheduled or increased. She added: It is situational. We look for the need and address it. She stated the responsibility for this belongs both to the nurses and to the providers (nurse practitioners and physicians). After reviewing R96's August 2024 MAR, she stated when the prn medications are being used as frequently as R96 was using them, the nurse practitioner or physician should have made an adjustment. On 8/29/24 at 9:40 a.m., ASM #4, the nurse practitioner, was interviewed. She stated she has just started getting to know the residents at this facility. She stated: I'm seeing a lot of people just on prn medications for pain. She stated if residents are requesting frequent prn pain medication, she would try to schedule a one-time nighttime dose. She added: I try to get them on a once or twice a day schedule, and move them to Tylenol instead of the opioids. After reviewing R96's August 2024 MAR, she stated: I would put him on an extended release opioid twice a day, and schedule it. He shouldn't have to ask for that much medication so frequently. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. A review of the facility policy, Pain Management, revealed, in part: Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Pain management is a multidisciplinary care process that includes .Monitoring for the effectiveness of interventions .Modifying approaches as necessary .If pain has not been adequately controlled, the multidisciplinary team, including the physician, may reconsider approaches and make adjustment as indicated. No further information was provided prior to exit. 2. For Resident #72 (R72), the facility staff failed to assess the resident's need for an increase in his scheduled pain medication. A review of R72's clinical record revealed the following orders: 7/23/24 Oxycodone (an opioid pain medication) Oral Tablet 10 mg (milligrams) .Give 2 tablets by mouth every 4 hours as needed for pain. 7/16/24 Oxycodone-Acetaminophen (Percocet, an opioid pain medication) 7.5 - 325 mg Give 1 tablet by mouth every 4 hours as needed for pain medication. A review of R72's August 2024 MAR (medication administration record) revealed he received a total of 49 as needed doses of Oxycodone or Percocet between 8/1/24 and 8/28/24. The review revealed pain level assessments prior to the administration of the pain medications to range primarily between 7 and 10. The as needed medications were administered over the entire range of days, evenings, and nights. On 8/28/24 at 12:38 p.m., ASM (administrative staff member) #4, the attending physician, was interviewed. When asked his role in monitoring prn (as needed) pain medication for residents, he stated a resident's frequent usage of a prn pain medication could be mentioned either by the resident or by the nurse. He stated: Certainly if the prns are being given around the clock, or the resident is frequently requesting a dose, something needs to be adjusted. He stated the resident's maintenance (scheduled) pain medication may need to be increased. He added this decision should take into account the reason for the pain, with the goal of getting the resident off of narcotic pain medications as soon as possible. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated when a resident requests a prn pain medication, the nurses try an alternative to the medication first. This could include repositioning or a warm/cold compress, depending on the nature of the pain and the resident's orders. She stated if the alternative interventions are unsuccessful in relieving the resident's pain, the nurse should administer the as needed medication. She stated when the nursing staff notices a trend of the resident being in constant pain, the nurses talk to the nurse practitioner to see if something needs to be scheduled or increased. She added: It is situational. We look for the need and address it. She stated the responsibility for this belongs both to the nurses and to the providers (nurse practitioners and physicians). After reviewing R72's August 2024 MAR, she stated when the prn medications are being used as frequently as R72 was using them, the nurse practitioner or physician should have made an adjustment. On 8/29/24 at 9:40 a.m., ASM #4, the nurse practitioner, was interviewed. She stated she has just started getting to know the residents at this facility. She stated: I'm seeing a lot of people just on prn medications for pain. She stated if residents are requesting frequent prn pain medication, she would try to schedule a one-time nighttime dose. She added: I try to get them on a once or twice a day schedule, and move them to Tylenol instead of the opioids. After reviewing R72's August 2024 MAR, she stated: I would put him on an extended release opioid twice a day, and schedule it. He shouldn't have to ask for that much medication so frequently. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility failed to provide evidence of communication with dialysis facility for Resident #56. Resident #56 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease) and diabetes. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 7/2/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan dated 9/29/22, which revealed, FOCUS: Resident has ESRD and receives Hemodialysis at Dialysis Center in Farmville M, W, F. Rt. upper chest catheter for dialysis access. INTERVENTIONS: Resident receives dialysis M, W, F. If bleeding from the vascular access is not controlled; apply direct pressure, call the Dialysis team/nephrologist to determine the need for resident to be transported emergently to the ED. A review of the physician's orders dated 8/5/24, revealed, Hemodialysis Mon, Wed, Fri. LogistiCare transport, pick up for 0935 chair time, return to facility 1355. A review of Resident #56's medical record evidenced the only dialysis communication form 7/1/24-8/28/24 was on 7/12/24. No other communication forms located. An interview was conducted on 8/27/24 at 8:25 AM with Resident #56. When asked if they send a binder, folder or notebook with her to dialysis, Resident #56 stated, no, they do not send any paperwork with me. An interview was conducted on 8/29/24 at 2:20 PM with LPN (licensed practical nurse) #3. When asked the purpose of the dialysis communication sheets, LPN #3 stated, it is to provide information to the dialysis center about the resident. We document it in PCC (point click care), print and are to put them in a book or a folder and send with the resident. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's End Stage Renal Disease-Care of Resident policy revealed in part, Agreements between this facility and the contracted ESRD facility will include all aspects of how the residents care will be managed including but not limited to communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination and collaboration. No further information was provided prior to exit. 4. For Resident #63 (R63), the facility failed to provide evidence of implementing a fluid restriction related to dialysis. A review of R63's clinical record revealed the following order dated 8/23/24: Fluid restriction =1200 ml/day (milliliters per day): dietary 840 ml/day (B [breakfast]: 240 ml, L [lunch]: 360 ml, D [dinner]: 240 ml); nursing - 360 ml/day (120 ml q [each] shift). Further review of R63's clinical record, including August 2024 MARs (medication administration records), TARs (treatment administration records), and progress notes, revealed no evidence that the fluid restriction had been implemented. On 8/29/24 at 8:01 a.m., LPN (licensed practical nurse) #5, a unit manager, was interviewed. She stated the dietician is responsible for putting an order in for any kind of fluid restriction. It is the nurses' responsibility to document the resident's fluid intake on each shift. After reviewing R63's order, MAR, and TAR, she stated: There is no documentation about this order because it was put in as 'no documentation required.' The dietician put the order in wrong. LPN #5 stated R63 receives dialysis, and the fluid restriction is intended to prevent the resident from becoming fluid overloaded. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 5. For Resident #22 the facility staff failed to evidence consistent communication with (to and from) the dialysis center. A review of the clinical record revealed the following regarding dialysis services from 6/1/24 through the survey date of 8/28/24: A review of the clinical record revealed physician's orders dated 5/17/24, 7/17/24, 7/31/24, and 8/5/24 that all documented the resident was to receive dialysis services every Monday, Wednesday and Friday. A review of the clinical record revealed a Pre and Post Dialysis Review form completed by the facility, to be printed and sent to the dialysis facility with the resident. The record revealed that this form was not completed on 6/14/24, 6/19/24, 6/21/24, 7/26/24, 8/19/24 and 8/21/24 and therefore could not be provided to the dialysis center. In addition, Post Dialysis Communication forms provided to the facility from the dialysis center were reviewed for the months of June, July and August, 2024. Only eight dates were provided (6/7/24, 6/10/24, 6/17/24, 6/19/24, 6/21/24, 7/12/24, 7/26/24, and 8/7/24). All other dialysis dates from 6/1/24 through 8/28/24 were not provided, evidencing that the dialysis center did not provide post dialysis communication to the facility. These dates were 6/3/24, 6/5/24, 6/12/24, 6/14/24, 6/24/24, 6/26/24, 6/28/24, 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/10/24, 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/29/24, 7/31/24, 8/2/24, 8/5/24, 8/9/24, 8/12/24, 8/14/24, 8/16/24, 8/19/24, 8/21/24, 8/23/24, and 8/26/24. On 8/30/24 at 10:53 AM an interview was conducted with LPN #1 (Licensed Practical Nurse). She stated that the nurse does the pre dialysis form which should include information regarding if any meds were given, if resident ate, blood sugar, then print the form and it is put in the binder and goes with them. She stated that the dialysis center is supposed to send post-dialysis information, including pre and post dialysis weight, how much fluid was removed, any medications administered, any effects or complications the resident had, post dialysis vitals, etc., are supposed to be sent back. She stated that has not been happening. The facility policy, End Stage Renal Disease - Care of Resident documented, Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to: b. the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination, and collaboration On 3/29/24 at the end of day meeting at approximately 3:40 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #6 a Director of Clinical Operations, ASM #7 a Regional Director of Clinical Operations, ASM #8 a Regional Director of Operations, and RN #4 (Registered Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services related to dialysis for five of 50 residents in the survey sample, Residents #101, #109, #56, #63 and #22. The findings include: 1a. For Resident #101, the facility staff failed to ensure a resident was transported to dialysis, thus the resident did not receive dialysis on 8/24/24. The nurse's notes dated 8/24/24 at 10:49 a.m. documented, Resident was not picked up for dialysis this morning. Attempted to locate contact information for transportation, unable to locate. Called (initials of company) Dialysis spoke to the nurse, and she was also unable to located contact information for transportation, but there also was no more chair time availability for resident. I updated the resident, nursing supervisor and left a vm (voicemail) for the resident's niece. The physician order dated 8/27/24 documented, Dialysis Tues, Thurs, Sat, at (initials of dialysis center) Farmville 6:10 - 9:40 am chair time. Arrive at 5:40 a.m. Dialysis transport provided by (name of company and phone number). An interview was conducted on 8/28/24 at 1:28 p.m. with ASM (administrative staff member) #1, the administrator. ASM #1 stated, the facility transportation takes the residents to dialysis even on the weekend. An interview was conducted with OSM (other staff member) #14, the receptionist/transportation coordinator, on 8/28/24 at 3:08 p.m. When asked who schedules transportation for residents to go to dialysis, OSM #14 stated it's usually herself. When asked who transports R101 to dialysis, OSM #14 stated, the resident goes through Medicaid to dialysis. When asked if that includes weekends, OSM #14 stated, yes. OSM #14 was asked what happens on the weekend if the scheduled transportation doesn't show to take the resident to dialysis, OSM #14 stated, the nurse should contact the backup driver/facility drivers, so they would transport the resident. The nurse's note above was shared with OSM #14. She stated that she was unaware of the resident missing dialysis. When asked who has access to the number for the transportation for R101, OSM #14 stated the number is taped to her desk and anyone has access to the number. OSM #13 was asked fi the staff is aware of a transportation problem, do the staff know who the backup person/transportation is, OSM #13 stated, they should know. The comprehensive care plan dated, 7/13/24, documented in part, Focus: (R101) has ESRD (end stage renal disease) and receives hemodialysis @ (Name and address of dialysis center), Tues. Thurs, Sat @ 6:10 a.m. Goal: The resident will not experience any unavoidable complications from dialysis through the next review dated. The Interventions documented in part, Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. The facility policy, End Stage Renal Disease - Care of the Resident., documented in part, The nursing facility will assist the resident requiring hemodialysis with arrangement for safe transportation to and from the hemodialysis center. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 1b. For Resident #101, the facility staff failed to have communication with the dialysis center when the resident went to dialysis. An interview was conducted with R101 on 8/26/24 at approximately 5:00 p.m. When asked if she takes any paperwork, a binder or folder with her when she goes to dialysis, R101 stated, no, she doesn't take anything like that with her. The physician order dated 8/27/24 documented, Dialysis Tues, Thurs, Sat, at (initials of dialysis center) Farmville 6:10 - 9:40 am chair time. Arrive at 5:40 a.m. Dialysis transport provided by (name of company and phone number). Since admission, the resident should have gone to the dialysis center 19 times between 7/16/24 and 8/27/24. On 8/10/24, the resident refused to go. On 8/24/24, the transportation company did not pick up the resident, so she missed that treatment. Of those 17 times, there was only one Pre and Post Dialysis Review form. Review of the clinical record revealed a Pre and Post Dialysis Review dated, 7/18/24. It documented the resident left the facility at 4:47 a.m. The vital signs documented under the Pre-Dialysis section were dated, 7/16/24. The Post Dialysis section documented the same vital signs as in the Pre-Dialysis section. There were no weights documented Pre or Post Dialysis. There were no other Pre and Post Dialysis Review forms. A request was made for the communication forms for the resident's date of treatments at the dialysis center. On 8/28/24 at 9:53 a.m., ASM #1, the administrator, stated the facility did not have any communication with dialysis for R101. An interview was conducted with RN (registered nurse) #5 on 8/29/24 at 12:40 p.m. When asked what should happen when a resident goes to dialysis, RN #5 stated, normally they have a snack to go with them. The residents should be up and dressed and ready. RN #5 was asked if the residents take any paperwork with them, RN #5 stated, if there is a change in their medications, she would send the medication list. When asked if the residents take a folder or binder with them when they go, RN #5 stated yes. When asked what is in the binder/folder, RN #5 stated, a face sheet, medication list, if the resident is a DNR (do not resuscitate), a copy of that. RN#5 was asked if this should go with the resident each time they go, RN #5 stated, yes. When asked if the paperwork sent with the resident comes back from the dialysis center, RN #5 stated, some centers print them off, most of them will fax over anything that they need to know. RN #5 was asked if the nurse who gets the resident upon return from dialysis should look for paperwork to return, RN #5 stated, yes. When asked how they communicate with the dialysis centers, RN #5 stated they have the centers phone number in the resident's chart, and they can call them if they need to. The facility policy, End Stage Renal Disease - Care of the Resident., documented in part, 3. Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to: b. The communication process between the nursing facility and the dialysis center that will reflect on going communication, coordination, and collaboration. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 1c. For Resident #101, the facility staff failed to monitor a physician ordered fluid restriction. The physician order dated, 7/31/24, documented, Fluid Restriction 1200 ml/day (milliliters/day); dietary - 840 ml/day (B [breakfast} - 240 ml, L [lunch] 360 ml, D [dinner] 240 ml; nursing: 360 ml/day (120 ml Q [every] shift) - ONS (ordered nutritional supplements) not included in fluid restriction. The August 2024 MAR (medication administration record) documented the above physician order. On the following dates there was nothing documented: 8/12/24 - day shift and 8/24/24 - night shift. On the following dates and shift an NA(not applicable) was documented: Day shift on 8/1/14, 8/3/24, 8/4/24, 8/8/24, 8/16/24, 8/17/24, 8/25/24. Evening shift on 8/16/24 and 8/17/24. Night shift on 8/16/24. The comprehensive care plan dated, 7/17/24, documented in part, Focus: (R101) is at risk for malnutrition r/t (related to) adenocarcinoma (cancer), new HD (hemodialysis) r/t ESRD. The Interventions documented in part, Fluid Restriction 1200 ml/day (milliliters/day); dietary - 840 ml/day (B [breakfast] - 240 ml, L [lunch] 360 ml, D [dinner]) 240 ml; nursing: 360 ml/day (120 ml Q [every] shift) - ONS (ordered nutritional supplements) not included in fluid restriction. An interview was conducted with RN #5 on 8/29/24 at 12:40 p.m. When asked if a resident is on a fluid restriction, where is that documented, RN #5 stated on the eMAR (electronic medication administration record). RN #5 was asked what NA would mean when documenting under the fluid restriction order, RN #5 stated, normally NA means not applicable but that wouldn't make sense on that order. When asked what should be documented on the eMAR, RN #5 stated, a numerical number. The facility policy, Resident Hydration and Prevention of Dehydration documented in part, Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increase a risk for dehydration. ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit. 2. For Resident #109 (R109), the facility staff failed to have communication with the dialysis center when the resident went to dialysis. R109 was admitted to the facility on [DATE]. The physician order dated, 12/13/23, documented, Dialysis at (name and address of dilayss center) on Tues, Thurs, Sat at 10:35 a.m. The resident was scheduled to go to dialysis on 12/14/23. Review of the clinical record, failed to evidence communication with the dialysis center. A request was made for any communication with the dialysis center on 12/14/23. On 8/28/24 at 9:53 a.m. ASM #1, the administrator, stated they had no documentation of communication with the dialysis center for 12/14/23. An interview was conducted with RN (registered nurse) #5 on 8/29/24 at 12:40 p.m. When asked what should happen when a resident goes to dialysis, RN #5 stated, normally they have a snack to go with them. The residents should be up and dressed and ready. RN #5 was asked if the residents take any paperwork with them, RN #5 stated, if there is a change in their medications, she would send the medication list. When asked if the residents take a folder or binder with them when they go, RN #5 stated yes. When asked what is in the binder/folder, RN #5 stated, a face sheet, medication list, if the resident is a DNR (do not resuscitate), a copy of that. RN#5 was asked if this should go with the resident each time they go, RN #5 stated, yes. When asked if the paperwork sent with the resident comes back from the dialysis center, RN #5 stated, some centers print them off, most of them will fax over anything that they need to know. RN #5 was asked if the nurse who gets the resident upon return from dialysis should look for paperwork to return, RN #5 stated, yes. When asked how they communicate with the dialysis centers, RN #5 stated they have the centers phone number in the resident's chart, and they can call them if they need to. ASM #1, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility failed to provide adequate nursing staff for two of 50 residents in the survey sample, Residents #107 and #112. The findings include: 1. For Resident #107 (R107), the facility failed to provide adequate nursing staff on the resident's unit for night shift (11:00 p.m. through 7:30 a.m.) on multiple nights in September and October 2023. A review of nursing staff records for September and October 2023 revealed one licensed nurse and one CNA (certified nursing assistant) on the night shift on 9/22, 9/24, 9/30, 10.4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/14, and 10/16 's on R107's unit during the resident's stay. The resident census on this unit was between 25 and 30 on each of these nights. On 8/29/24 at 10:21 a.m., CNA #6, the staff scheduler, was interviewed. She stated she assigns staff to units according to a form given to her by corporate. She stated this form tells her how many staff each unit needs according to census and acuity. She stated: We talk to the unit managers about acuity, then we schedule according to acuity within the budget. She stated R107's unit has a total of 30 beds, and requires a minimum of one licensed nurse and two CNAs on the night shift. She stated: The only they work with only one CNA on that unit at night is if we have call outs. Our plan calls for a minimum of two CNAs. On 8/29/24 at 3:20 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated R107's unit is staffed based on acuity and census. She stated: We use our staffing grid provided to us by corporate. She stated the unit can have high acuity residents since it is a skilled nursing unit. It is a 30 bed unit. She added the night shift requires one licensed nurse and a minimum of two CNAs. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. A review of the facility policy, Staffing, revealed, in part: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services to all residents in accordance with resident care plans and the facility assessment .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. No further information was provided prior to exit. 2. For Resident #112 (R112), the facility failed to provide adequate nursing staff on the resident's unit for night shift (11:00 p.m. through 7:30 a.m.) on 8/26/23. A review of nursing staff records for 8/26, 2023 revealed one licensed nurse and one CNA (certified nursing assistant) on the night shift. The resident census was 26 on this night. On 8/29/24 at 10:21 a.m., CNA #6, the staff scheduler, was interviewed. She stated she assigns staff to units according to a form given to her by corporate. She stated this form tells her how many staff each unit needs according to census and acuity. She stated: We talk to the unit managers about acuity, then we schedule according to acuity within the budget. She stated R107's unit has a total of 30 beds, and requires a minimum of one licensed nurse and two CNAs on the night shift. She stated: The only they work with only one CNA on that unit at night is if we have call outs. Our plan calls for a minimum of two CNAs. On 8/29/24 at 3:20 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated R107's unit is staffed based on acuity and census. She stated: We use our staffing grid provided to us by corporate. She stated the unit can have high acuity residents since it is a skilled nursing unit. It is a 30 bed unit. She added the night shift requires one licensed nurse and a minimum of two CNAs. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for two of 50 residents in the survey sample, Resident #113 and Resident #26. The findings include: 1.The facility staff failed to ensure Resident #113 was free of unnecessary medications by administering anticoagulant as ordered. Resident #113 was admitted to the facility on [DATE] with diagnosis that included fractures and hypertension. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and independent for eating. A review of the baseline care plan dated 8/3/23 revealed, FOCUS: Resident has actual impairment to skin integrity related to Surgical Wound. INTERVENTIONS: Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. There is no evidence of the baseline care plan including any focus or interventions related to anticoagulation therapy or monitoring. A review of the physician order dates 7/21/23 revealed Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML. Inject 0.4 ml subcutaneously every 12 hours. A review of the July and August 2023 MAR (medication administration record) reveals scheduled time for Enoxaparin injection scheduled for 12:00 AM and 12:00 PM. Review of the administration times reveals the following delays in administration of Enoxaparin: 7/22- 3:28 AM and 1:30 PM, 7/24-1:30 PM, 7/31-1:21 AM and 1:37 PM, 8/2-5:00 AM and 1:29 PM, 8/5-2:42 PM, 8/6-1:24 PM, 08/7-1:24 PM, 8/8-2:54 PM, 8/10-1:15 PM, 8/11-3:26 AM and 1:10 PM and 8/12-1:50 AM and 4:17 PM. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked where the evidence of anticoagulation injections would be located, LPN #2 stated, it would be on the MAR. When asked if the physician orders for anticoagulation medication administration were not followed, were professional standards followed, LPN #2 stated, no, they would not be followed. When asked if not administering anticoagulant as ordered every 12 hours was keeping the resident free of unnecessary medications, LPN #2 stated, no, it is not. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Medication Administration policy revealed in part, This policy establishes the guidelines for the safe and effective administration of medications at Hill Valley Healthcare. All medications administered within the facility are subject to these guidelines. The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed at the following stages during medication administration. No further information was provided prior to exit. 2.The facility staff failed to ensure Resident #26 was free of unnecessary medications by administering anticoagulant as ordered. Resident #26 was admitted to the facility on [DATE] with diagnosis that included CHF (congestive heart failure), DM (diabetes mellitus) and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 6/11/24, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and independent for eating. A review of the comprehensive care plan dated 4/9/24 revealed, FOCUS: Resident is on anticoagulant therapy related to Atrial fibrillation. INTERVENTIONS: Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. A review of the physician order dates 5/14/24 revealed Apixaban Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for afib. A review of the June, July and August 2024 MAR-TAR (medication administration record-treatment administration record) found no evidence of the resident being monitored for adverse reactions of anticoagulant therapy as ordered. An interview was conducted on 8/27/24 at 2:45 PM with LPN (licensed practical nurse) #2. When asked where the evidence of anticoagulation monitoring would be located, LPN #2 stated, it would be on the TAR. When asked if the physician orders for anticoagulation medication monitoring were not followed, were professional standards followed, LPN #2 stated, no, they would not be followed. When asked if not monitoring the resident receiving anticoagulants was keeping the resident free of unnecessary medications, LPN #2 stated, no, it is not. On 8/28/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Medication Administration policy revealed in part, This policy establishes the guidelines for the safe and effective administration of medications at Hill Valley Healthcare. All medications administered within the facility are subject to these guidelines. The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed at the following stages during medication administration. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to serve palatable food for five of 33 residents in the survey sample, Residents #24, #96, #34, #157, and #32. The findings include: The facility staff failed to serve food with a palatable flavor and at an appetizing temperature. On R24's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 7/14/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/26/24 at 2:18 p.m., an interview was conducted with R24. The resident stated the food at the facility was edible but that was all they would say about it. R24 stated that they had lost weight since they were at the facility, but it was desired due to the food quality and the food was usually cold. On R96's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/16/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/26/24 at 2:46 p.m., an interview was conducted with R96. The resident stated the food served at the facility lacks in taste and temperature. R96 stated, I would not serve this food to my dog. On R34's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/24/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/26/24 at 3:45 p.m., an interview was conducted with R34. The resident stated the food at the facility doesn't taste good. On R157's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/13/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 8/26/24 at 3:55 p.m., an interview was conducted with R157. The resident stated the facility food was cold and did not have any taste. On R32's most recent MDS (minimum data set), a quarterly assessment with an ARD of 6/8/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/26/24 at 4:40 p.m., an interview was conducted with R32. The resident stated the food at the facility was normally served cold when it was supposed to be hot, and the cold items were normally room temperature. On 8/26/24 at 5:32 p.m., a meal test tray was conducted with OSM (other staff member) #1 (the dietary manager) as the last meal was being served on the last unit. The food did not have a palatable flavor or appetizing temperature. The ground pork was 99 degrees Fahrenheit, the coleslaw was 69 degrees Fahrenheit, the pureed pork was 114 degrees Fahrenheit, and the pureed vegetables were 114 degrees Fahrenheit. OSM #1 stated the ground pork was a little bland and could be a little warmer. OSM #1 stated the coleslaw was a little vinegary. OSM #1 stated the pureed pork was a little bland and did not taste like pork, and the pureed vegetables could be a little warmer. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food and Nutrition Services documented, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. No further information was presented prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required in-services trainings for three of five CNA record reviews. The findings include: The facility staff failed to evidence 12 hours of annual training was provided to CNA #3, #4, and #5. CNA #3 was hired on 5/19/22. A review of CNA #3's employee record revealed the CNA only received 10 hours of annual in-service trainings. CNA #4 was hired on 6/22/22. A review of CNA #4's employee record revealed the CNA only received 4.5 hours of annual in-service trainings. CNA #5 was hired on 3/24/23. A review of CNA #5's employee record revealed the CNA only received 2.75 hours of annual in-service trainings. On 8/28/24 at 11:45 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing). ASM #2 stated the facility recently began utilizing a computer software for trainings. ASM #2 stated she would have to put something in place to make sure required trainings are being completed by staff. ASM #1 and ASM #2 were made aware of the above concern. The facility policy titled, Nurse Aide In-Service Training Program documented, 4. Annual in-services: b. Are no less than 12 hours per employment year or according to state law. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain the garbage areas in a sanitary manner for one of one trash compactor and two of ten trash bins. The findings include: The facility staff failed to ensure the door/lids on the trash compactor and two trash bins were kept closed when not in use. On 8/26/24 at 4:00 p.m., an observation of the trash compactor was conducted. The side door of the compactor was open and multiple bags of trash were observed in the compactor. On 8/27/24 at 1:52 p.m., an observation of the outside trash bins was conducted. The lids on two bins were open and multiple bags of trash were observed in the bins. On 8/27/24 at 2:43 p.m., an interview was conducted with OSM (other staff member) #2 (the regional director of maintenance) and OSM #3 (the maintenance director). OSM #2 stated the side door on the trash compactor and the lids on the trash bins should be kept closed to keep animals out. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food-Related Garbage and Refuse Disposal documented, 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a complete infection control program and implement infection control practices for one of 50 residents in the survey sample, Resident #33. The findings include: 1. The facility staff failed to evidence infection surveillance for January 2023 through December 2023. A review of the facility infection control program for January 2023 through December 2023 failed to reveal a system of surveillance. There was only a binder containing multiple Antibiotic Timeout forms for multiple residents. On 8/28/24 at 9:16 a.m., an interview was conducted with RN (registered nurse) #4 (the infection control nurse who was not employed at the facility during 2023). RN #4 stated every day he documents all infections on a tracking log spreadsheet then color codes the infections on a floor plan of rooms so he can evaluate if there is a group of a certain infection and so he knows if there is an infection control challenge that he needs to address. RN #4 was shown the 2023 binder of antibiotic timeout forms and stated it was not possible to track and identify clusters of infections if only those forms were utilized. On 8/28/24 at 11:44 a.m , ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Infection Prevention and Control Program documented, 6. Surveillance- a. Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP (infection prevention and control program) effectiveness. b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. No further information was presented prior to exit. 2. For Resident #33 (R33), RN (registered nurse) #2 failed to implement infection control practices while preparing and administering medications to the resident. On 8/26/24 at 4:21 p.m., RN #2 was observed preparing medications for R33. RN #2 dropped a 100 mg (milligrams) tablet of bupropion (an antidepressant medication) on top of the medication cart then picked the tablet up with his bare hand and placed the pill in the medication cup. RN #2 placed two other pills in the medication cup then stated the tablet of bupropion was the wrong medication. RN #2 placed his finger in the medication cup to hold the two other pills in the cup while he disposed of the bupropion. RN #2 placed another medication into the medication cup then administered the medications to R33. On 8/27/24 at 3:01 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a pill is dropped on top of the medication cart, then it should be discarded. LPN #1 stated that if there are multiple pills in a medication cup and one pill needs to be discarded, she would discard all pills and re-pour the medications or a nurse should put on gloves to remove the pill from the cup. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern and the facility did not have a specific policy regarding the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, facility document review, and clinical record review, the facility staff failed to treat a resident with dignity by not answering a call bell for one of six residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to answer her call bell in a timely manner on 5/6/24. A review of R6's admission nursing assessment dated [DATE] revealed the resident had no cognitive impairment for making daily decisions. On 5/6/24 at 2:02 p.m., the call light outside R6's room was on. Between 2:02 p.m. and 2:52 p.m., six different staff members walked by R6's room without acknowledging or answering the call bell. During this time, two staff members were seated at the nursing station talking to each other, one staff member was seated in the day room working on the computer, and one nurse was on R6's hall administering medications to other residents. At 2:52 p.m., a staff member entered R6's room and turned off the call bell. On 5/7/24 at 12:44 p.m., R6 was interviewed. She stated she waited over two hours the previous day for someone to answer her call bell. She stated she had a question for the nurse. When asked how it made her feel when she had to wait to so long for the call bell to be answered, she stated: I feel like I am not important enough. I feel like nobody has time to take care of me. She stated she is a worrier, and gets frantic when no staff member answers her call bell over that much time. On 5/7/24 at 10:51 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated call bells should be answered by anyone who sees it, even if they are not a nursing staff member. She stated: I answer it as soon as I see it. That's how it should be. On 5/7/24 at 11:51 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated all staff are responsible for answering a call bell. She stated if a staff member is not providing resident care or administering medications, that person should answer the call bell as soon as it rings. She stated: The bells don't ring at the desk. You have to actually be able to see the light outside the resident's room to know it is on. On 5/7/24 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Answering the Call Light, revealed, in part: Call lights may be answered by any staff member; if the resident needs assistance that cannot be provided by the staff member answering the light, the staff member will promptly notify a staff member who can assist the resident. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for two of six residents in the survey sample, Residents #5 and #6. The findings include: 1. For Resident #5 (R5), the facility staff failed to implement the care plan for the administration of respiratory medications. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. She was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease) (1), pulmonary edema (2), and chronic respiratory failure. On 5/6/24 at 2:02 p.m., R5 was observed sitting up in bed. She was receiving oxygen via nasal cannula. She stated she has trouble breathing, and is concerned that she is not receiving her breathing treatments on time. She stated: They give them to me when they feel like it. A review of R5's medication orders revealed the following: 4/24/24 Budesonide Inhalation Suspension 0.5 MG/2ML (milligrams per milliliter) (Budesonide (Inhalation) 1 vial inhale orally two times a day related to acute and chronic respiratory failure. (3) 4/24/24 Formoterol Fumarate Inhalation Nebulization Solution 20 MCG/2ML (Formoterol Fumarate) 1 vial inhale orally via nebulizer two times a day related to chronic obstructive pulmonary disease with exacerbation. Discontinued 5/1/24. (4) 4/24/24 Ipratropium Bromide Inhalation Solution 0.02 % (Ipratropium Bromide) 1 vial inhale orally four times a day related to acute and chronic respiratory failure. Discontinued 5/1/24. (5) 4/24/24 Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/3ML (Levalbuterol HCl) 1 vial inhale orally via nebulizer four times a day related to chronic obstructive pulmonary disease with exacerbation. Discontinued 5/1/24. (6) A review of R5's care plan dated 4/26/24 revealed, in part: [R5] has .COPD/Respiratory Failure, Pulmonary Edema .Give aerosol or bronchodilators as ordered. A review of R5's MARs (medication administration records) from 4/24/24 through 5/3/24 revealed the following medication due times/times they were administered: 4/24/24 Formoterol and Budesonide 6:00 p.m./9:14 p.m. 4/25/24 Formoterol 7:00 a.m./9:28 a.m. 4/26/24 Budesonide 6:00 a.m./8:28 a.m. 4/27/24 Ipatropium and Levalbuterol 12:00 a.m./2:56 a.m. 4/27/24 Formoterol 6:00 p.m./9:52 p.m. 4/28/24 Budesonide 6:00 a.m./8:16 a.m. 4/28/24 Fomoterol and Budesonide 6:00 p.m./7:54 p.m. 4/29/24 Budesonide 6:00 a.m./9:09 a.m. 4/29/24 Formoterol 7:00 a.m./9:07 a.m. 4/29/24 Ipatropium and Levalbuterol 12:00 p.m./3:24 p.m. 4/30/24 Ipatropium and Levalbuterol 6:00 a.m./not administered 4/30/24 Budesonide 6:00 a.m./10:46 a.m. 4/30/24 Formoterol 7:00 a.m./10:57 a.m. 4/30/24 Levalbuterol 12:00 noon/3:04 p.m. 4/30/24 Budesonide and Formoterol 6:00 p.m./10:21 p.m. 4/30/24 Ipatropium 12:00 noon/3:04 p.m. 5/1/24 Ipatropium and Levalbuterol 6:00 a.m./not administered 5/1/24 Budesonide 6:00 a.m./10:26 a.m. 5/1/24 Formoterol 7:00 a.m./not administered 5/2/24 Budesonide 6:00 a.m./7:53 a.m. 5/3/24 Budesonide 6:00 a.m./8:25 a.m. 5/3/24 Budesonide 6:00 p.m./9:28 p.m. On 5/7/24 at 11:51 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated the care plan tells the staff what to do for the resident. She stated: The whole team should be working toward the care plan goals. On 5/7/24 at 2:40 p.m., ASM #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Care Planning - Interdisciplanry Team, revealed no information related to the implementation of the comprehensive care plan. No further information was provided prior to exit. References (1) COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. Progressive means the disease gets worse over time. COPD can cause coughing that produces large amounts of a slimy substance called mucus, wheezing, shortness of breath, chest tightness, and other symptoms. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/copd. (2) Pulmonary edema is an abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath. This information is taken from the website https://medlineplus.gov/ency/article/000140.htm. (3) Budesonide (Entocort EC) is used to treat Crohn's disease (a condition in which the body attacks the lining of the digestive tract, causing pain, diarrhea, weight loss, and fever). Budesonide (Tarpeyo) is used to decrease protein in the urine in patients with primary immunoglobulin A nephropathy (kidney disease that occurs in some people when too much immunoglobin A builds up in the kidney, causing inflammation). Budesonide is in a class of medications called corticosteroids. It works by decreasing inflammation (swelling) in the digestive tract of people who have Crohn's disease or in the kidney of people with nephropathy. This information is taken from the website https://medlineplus.gov/druginfo/meds/a608007.html. (4) Formoterol oral inhalation is used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease (COPD; a group of lung diseases that includes chronic bronchitis and emphysema). Formoterol is in a class of medications called long-acting beta agonists ([NAME]). It works by relaxing and opening air passages in the lungs, making it easier to breathe. This information is taken from the website https://medlineplus.gov/druginfo/meds/a602023.html#:~:text=Formoterol%20oral%20inhalation%20is%20used,acting%20beta%20agonists%20([NAME]). (5) Ipratropium oral inhalation is used to prevent wheezing, shortness of breath, coughing, and chest tightness in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Ipratropium is in a class of medications called bronchodilators. It works by relaxing and opening the air passages to the lungs to make breathing easier. This information is taken from the website https://medlineplus.gov/druginfo/meds/a695021.html. (6) Levalbuterol is used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness caused by lung disease such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways). Levalbuterol is in a class of medications called beta agonists. It works by relaxing and opening air passages to the lungs to make breathing easier. This information is taken from the website https://medlineplus.gov/druginfo/meds/a603025.html. 2. For Resident #6, (R6), the facility staff failed to follow the care plan to answer the call bell in a timely manner. A review of R6's admission nursing assessment dated [DATE] revealed the resident had no cognitive impairment for making daily decisions. On 5/6/24 at 2:02 p.m., the call light outside R6's room was on. Between 2:02 p.m. and 2:52 p.m., six different staff members walked by R6's room without acknowledging or answering the call bell. During this time, two staff members were seated at the nursing station talking to each other, one staff member was seated in the day room working on the computer, and one nurse was on R6's hall administering medications to other residents. At 2:52 p.m., a staff member entered R6's room and turned off the call bell. On 5/7/24 at 12:44 p.m., R6 was interviewed. She stated she waited over two hours the previous day for someone to answer her call bell. She stated she had a question for the nurse. When asked how it made her feel when she had to wait to so long for the call bell to be answered, she stated: I feel like I am not important enough. I feel like nobody has time to take care of me. She stated she is a worrier, and gets frantic when no staff member answers her call bell over that much time. A review of R6's care plan dated 5/6/24 revealed, in part: [R6] has an algeration in musculoskeletal status .Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. On 5/7/24 at 10:51 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated call bells should be answered by anyone who sees it, even if they are not a nursing staff member. She stated: I answer it as soon as I see it. That's how it should be. On 5/7/24 at 11:51 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated the care plan tells the staff what to do for the resident. She stated: The whole team should be working toward the care plan goals. On 5/7/24 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer and/or accurately document administration of medications according to professional standards of practice for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff documented that the resident refused a nicotine patch when it was not yet available from the pharmacy, and documented the medication was applied when it actually had not been applied. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. On 5/6/24 at 2:02 p.m., R5 was interviewed. She stated she had been having trouble getting her nicotine patch applied. She stated it had not been applied daily, and some nurses told her she was not to receive a new patch every day. She stated she needed the patch because she is addicted to cigarettes, and cannot smoke in the facility. A review of R5's clinical record revealed the following order dated 4/26/24: Nicotine Step 3 Transdermal Patch 24 Hour 7 MG/24HR (milligrams per 24 hours) (Nicotine) Apply 1 patch transdermally one time a day for nicotine addiction for 14 Days. A review of the pharmacy manifest for R5 revealed 14 nicotine patches for were delivered to the facility at approximately 7:15 p.m. on 4/30/24. A review of R5's April and May 2024 MAR revealed coding that she refused the nicotine patch on 4/27, 4/28, and 4/29; the coding revealed she was administered the nicotine patch on 4/30, 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, and 5/7. On 5/7/24 at 9:38 p.m., an observation was made of R5's medication supply. The pouch of nicotine patches contained nine patches. LPN #1 stated the nicotine patch for 5/7/24 had already been applied. On 5/7/24 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. ASM #2 was asked if she could explain the fact that, per the MAR, eight of the 14 nicotine patches had been administered, yet there were still nine of the 14 patches available for administration. She stated she could not. When asked if nurses had signed off on administering the patches when they actually had not, she agreed. When asked if she had any explanation for nurses documenting that a resident had refused the patch three days in a row when the medication was not even available for administration, she stated she did not. On 5/7/24 at 3:05 p.m., LPN (licensed practical nurse) #2 was interviewed. She had documented the resident's refusal of the nicotine patch on 4/28/24, and as having given the nicotine patch on 5/2/24 through 5/5/24. When asked if she remembered anything about R5's nicotine patch, she stated: I think she didn't want the patch. I think she refuses it sometimes. When asked how the resident was able to refuse a patch when it had not yet arrived from the pharmacy, she stated: I'm not sure. Maybe I got confused. She stated: I have been working a lot of doubles. I might have done something wrong. I just don't remember. A review of the facility policy, Medication and Treatment Orders, revealed no information related to accurate administration and documentation of medication administration and refusal. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order for one of six residents in the survey, Resident #4. The findings include: For Resident #4 (R4), the facility failed to obtain daily weights as ordered to monitor the resident's cardiac status. R4 was most recently readmitted to the facility on [DATE] with diagnoses which included congestive heart failure (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/22/24, R4 was coded as being moderately cognitively impaired for making daily decisions. On 5/7/24 at 9:22 a.m., R4 was observed sitting up in a wheelchair in her room. When asked if the facility staff had been weighing her every day, she stated: I'm not sure. But I don't think so. A review of R4's clinical record revealed the following order dated 4/20/24: Daily Weights one time a day for Daily Weight. Call Cardiology at [phone number] for any weight loss or gain of 3 pounds overnight or 5 pounds in a week or increase in heart failure symptoms. A review of R4's April and May 2024 MARs (medication administration records) revealed no weights on 4/23 through 4/27; and no weights on 5/2, 5/2, or 5/4. On 5/7/24 at 10:51 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated if a resident has orders for daily weights, the CNAs weigh the resident. She stated she records the weight on a sheet of paper that has vital signs and weight information for each resident every day. She stated: I'm not sure what the nurse does with it after that. On 5/7/24 at 11:51 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated if a resident has an order daily weights, the CNAs weigh the residents. The nurses enter the weights into the electronic medical record. She added: If the weight is not in range, we may need to re-weigh the resident. She stated the daily weight is used as a way to monitor the effects of a resident's heart failure. She stated these can include either too much or too little fluid. On 5/7/24 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Weight Assessment and Intervention, revealed no information related to daily weights to monitor heart function. No further information was provided prior to exit. Reference (1) Heart failure is a condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body .As the heart's pumping becomes less effective, blood may back up in other areas of the body. Fluid may build up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called congestive heart failure. This information is taken from the website https://medlineplus.gov/ency/article/000158.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory services in a timely manner for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff administered nebulizer treatments more than an hour late on multiple occasions between 4/24/24 and 5/3/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. She was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease) (1), pulmonary edema (2), and chronic respiratory failure. On 5/6/24 at 2:02 p.m., R5 was observed sitting up in bed. She was receiving oxygen via nasal cannula. She stated she has trouble breathing, and is concerned that she is not receiving her breathing treatments on time. She stated: They give them to me when they feel like it. A review of R5's medication orders revealed the following: 4/24/24 Budesonide Inhalation Suspension 0.5 MG/2ML (milligrams per milliliter) (Budesonide (Inhalation) 1 vial inhale orally two times a day related to acute and chronic respiratory failure. (3) 4/24/24 Formoterol Fumarate Inhalation Nebulization Solution 20 MCG/2ML (Formoterol Fumarate) 1 vial inhale orally via nebulizer two times a day related to chronic obstructive pulmonary disease with exacerbation. Discontinued 5/1/24. (4) 4/24/24 Ipratropium Bromide Inhalation Solution 0.02 % (Ipratropium Bromide) 1 vial inhale orally four times a day related to acute and chronic respiratory failure. Discontinued 5/1/24. (5) 4/24/24 Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/3ML (Levalbuterol HCl) 1 vial inhale orally via nebulizer four times a day related to chronic obstructive pulmonary disease with exacerbation. Discontinued 5/1/24. (6) A review of R5's MARs (medication administration records) from 4/24/24 through 5/3/24 revealed the following medication due times/times they were administered: 4/24/24 Formoterol and Budesonide 6:00 p.m./9:14 p.m. 4/25/24 Formoterol 7:00 a.m./9:28 a.m. 4/26/24 Budesonide 6:00 a.m./8:28 a.m. 4/27/24 Ipatropium and Levalbuterol 12:00 a.m./2:56 a.m. 4/27/24 Formoterol 6:00 p.m./9:52 p.m. 4/28/24 Budesonide 6:00 a.m./8:16 a.m. 4/28/24 Fomoterol and Budesonide 6:00 p.m./7:54 p.m. 4/29/24 Budesonide 6:00 a.m./9:09 a.m. 4/29/24 Formoterol 7:00 a.m./9:07 a.m. 4/29/24 Ipatropium and Levalbuterol 12:00 p.m./3:24 p.m. 4/30/24 Ipatropium and Levalbuterol 6:00 a.m./not administered 4/30/24 Budesonide 6:00 a.m./10:46 a.m. 4/30/24 Formoterol 7:00 a.m./10:57 a.m. 4/30/24 Levalbuterol 12:00 noon/3:04 p.m. 4/30/24 Budesonide and Formoterol 6:00 p.m./10:21 p.m. 4/30/24 Ipatropium 12:00 noon/3:04 p.m. 5/1/24 Ipatropium and Levalbuterol 6:00 a.m./not administered 5/1/24 Budesonide 6:00 a.m./10:26 a.m. 5/1/24 Formoterol 7:00 a.m./not administered 5/2/24 Budesonide 6:00 a.m./7:53 a.m. 5/3/24 Budesonide 6:00 a.m./8:25 a.m. 5/3/24 Budesonide 6:00 p.m./9:28 p.m. On 5/7/24 at 11:51 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated medications should be administered within a two hour timeframe of their due time. She stated: We can give them up to an hour before, or an hour after they are due. She stated residents with respiratory diseases need breathing treatments to help open up their lungs so that they can breathe more easily. On 5/7/24 at 12:54 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated medications should be administered within an hour before or an hour after the medication is due. On 5/7/24 at 2:40 p.m., ASM #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Medication and Treatment Orders, revealed no information related to administering medications in a timely manner. No further information was provided prior to exit. References (1) COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. Progressive means the disease gets worse over time. COPD can cause coughing that produces large amounts of a slimy substance called mucus, wheezing, shortness of breath, chest tightness, and other symptoms. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/copd. (2) Pulmonary edema is an abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath. This information is taken from the website https://medlineplus.gov/ency/article/000140.htm. (3) Budesonide (Entocort EC) is used to treat Crohn's disease (a condition in which the body attacks the lining of the digestive tract, causing pain, diarrhea, weight loss, and fever). Budesonide (Tarpeyo) is used to decrease protein in the urine in patients with primary immunoglobulin A nephropathy (kidney disease that occurs in some people when too much immunoglobin A builds up in the kidney, causing inflammation). Budesonide is in a class of medications called corticosteroids. It works by decreasing inflammation (swelling) in the digestive tract of people who have Crohn's disease or in the kidney of people with nephropathy. This information is taken from the website https://medlineplus.gov/druginfo/meds/a608007.html. (4) Formoterol oral inhalation is used to control wheezing, shortness of breath, and chest tightness caused by chronic obstructive pulmonary disease (COPD; a group of lung diseases that includes chronic bronchitis and emphysema). Formoterol is in a class of medications called long-acting beta agonists ([NAME]). It works by relaxing and opening air passages in the lungs, making it easier to breathe. This information is taken from the website https://medlineplus.gov/druginfo/meds/a602023.html#:~:text=Formoterol%20oral%20inhalation%20is%20used,acting%20beta%20agonists%20([NAME]). (5) Ipratropium oral inhalation is used to prevent wheezing, shortness of breath, coughing, and chest tightness in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Ipratropium is in a class of medications called bronchodilators. It works by relaxing and opening the air passages to the lungs to make breathing easier. This information is taken from the website https://medlineplus.gov/druginfo/meds/a695021.html. (6) Levalbuterol is used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness caused by lung disease such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways). Levalbuterol is in a class of medications called beta agonists. It works by relaxing and opening air passages to the lungs to make breathing easier. This information is taken from the website https://medlineplus.gov/druginfo/meds/a603025.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, facility document review, and clinical record review, the facility staff failed to store equipment in a manner to prevent infection for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to store the resident's nebulizer mask in a manner to prevent infection. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. She was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease) (1), pulmonary edema (2), and chronic respiratory failure. On 5/6/24 at 2:02 p.m., R5 was observed sitting up in bed. The drawer to the resident's bedside table was open. The resident's nebulizer mask, still attached to the nebulizer machine with tubing, was lying unprotected in the resident's drawer. The resident stated: That's where they put it when I'm finished with my treatments. The mask was in the same location on 5/7/24 at 9:38 a.m. when the resident was observed sitting up in bed. On 5/7/24 at 11:51 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated nebulizer masks should be stored in a plastic bag between uses. She stated the nurse should rinse the mask after every use, and place it in a plastic bag. She stated: We keep them in a plastic bag for infection control. She stated this helps prevent bacteria from getting into a resident's respiratory tract. She stated the masks and tubing should be changed out each week. On 5/7/24 at 2:40 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Equipment Change and Cleansing Procedure, revealed, in part: Small volume nebulizers are to be dated and changed weekly and stored in labeled plastic bag. No further concerns were identified prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for two of six residents in the survey sample, Residents #3 and #2. The findings include: 1. For Resident #3 (R3), the facility staff failed to implement the care plan for pain management. R3 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) and lung cancer that had spread to other parts of the body. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/30/23, R3 was coded as having no cognitive impairment for making daily decisions. A review of R3's provider's orders revealed the following order dated 8/29/23: Morphine Sulfate Oral Solution 100 mg/ml (milligrams per milliliter) Give 0.75 ml by mouth every 6 hours for pain related to [lung cancer.] A review of R3's August and September 2023 MARs (medication administration records) revealed R3 received Morphine more than an hour past the time they were due on the following dates and times: 9/2/23 at 1:56 a.m. (due at midnight); 9/2/23 at 7:27 a.m. (due at 6:00 a.m.); 9/2//23 at 2:02 p.m. (due at 12:00 p.m.); 9/2/23 at 8:01 p.m. (due at 6:00 p.m.); 9/4/23 at 4:21 a.m. (due at midnight). A review of R3's comprehensive care plan revealed, in part: The resident has risk for experiencing episodes of pain r/t (related to) neoplasm of the lung with mets (metastasis - spreading of cancer to other parts of the body) .Administer analgesia as per orders. On 9/12/23 at 10:03 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to let the facility staff know what the resident needs in all aspects of life at the facility. She stated everyone at the facility is in charge of implementing the care plan. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. ASM #2 stated the purpose of the care plan is to have goals and to capture a picture of the resident's needs. She stated that nursing is responsible for implementing the care plan. A review of the facility policy, Care Planning - Comprehensive, Person-Centered, revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .the resident will receive the services and/or items included in the plan of care. No further information was provided prior to exit. Reference: (1) Morphine is used to relieve moderate to severe pain. Morphine extended-release tablets and capsules are only used to relieve severe (around-the-clock) pain that cannot be controlled by the use of other pain medications. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682133.html. 2. For Resident #2 (R2), the facility staff failed to implement the care plan for pain management. R2 was admitted to the facility with diagnoses including multiple fractures of the leg and arm and muscle spasms. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/26/23, R2 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:28 p.m., R2 was interviewed and stated he does not receive his medications on time. He stated he does not understand why this is, and has talked to the nurses multiple times about it. He stated he has to ask for his scheduled Tylenol, and the nurses still do not administer it to him on time. R2 stated Tylenol is the only pain medicine he receives, and it is important to him to receive it on time. A review of R2's provider's orders revealed the following orders: 7/21/23 Acetaminophen Oral (Tylenol) 325 mg (milligrams) Give 3 tablets by mouth three times a day for pain. A review of R2's August and September 2023 MARs (medication administration records) revealed he received the following medications more than an hour past the time they were due: Tylenol - 9/1/23 at 10:20 a.m. (due at 9:00 a.m.), 9/3/23 at 10:25 a.m. (due at 9:00 a.m.);and not given at all on 9/1/23, 9/3/23, and 9/4/23 at 9:00 p.m. A review of R2's comprehensive care plan dated 7/22/23 and revised 8/3/23 revealed, in part: The resident has acute pain r/t (related to) multiple fractures related to MVA (motor vehicle accident .Administer analgesia as per orders. On 9/12/23 at 10:03 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to let the facility staff know what the resident needs in all aspects of life at the facility. She stated everyone at the facility is in charge of implementing the care plan. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. ASM #2 stated the purpose of the care plan is to have goals and to capture a picture of the resident's needs. She stated that nursing is responsible for implementing the care plan. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications according to the provider's orders and professional standards of medication administration for two of six residents in the survey sample, Residents #3 and #2. The findings include: 1. For Resident #3 (R3), the facility staff failed to administer Potassium Chloride (1), Famotidine (2), Colace (3), and Albuterol (4) in a timely manner. R3 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) and lung cancer that had spread to other parts of the body. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/30/23, R3 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:48 p.m., R3 was interviewed, and stated: I'm not sure I get my medicines at the right time always. They do give them to me pretty regularly. A review of R3's provider's orders revealed the following: 8/30/23 Colace Capsule 100 mg (milligrams) Give 1 capsule by mouth two times a day for constipation. 8/26/23 Famotidine 20 mg Give 1 tablet by mouth two times a day. 8/26/23 Potassium Chloride ER (extended release) 10 MEQ (milliequivalents) Give 1 tablet by mouth two times a day. 8/25/23 Albuterol Sulfate Nebulization Solution 0.083% 1 vial inhale orally via nebulizer three times a day for wheezing/shortness of breath. A review of R3's August and September 2023 MARs (medication administration records) revealed she received the following medications more than an hour past the time they were due: Potassium Chloride (due at 8:00 a.m.) - 8/27/23 at 9:29 a.m.; 9/2/23 at 9:47 a.m.; 9/4/23 at 9:06 a.m. Famotidine (due at 8:00 a.m.) - 8/27/23 at 9:29 a.m. Colace (due at 8:00 a.m.) - 9/2/23 at 9:47 a.m.; 9/4/23 at 9:26 a.m. Albuterol (due at 2:00 p.m.) - 9/4/23 at 3:49 p.m. On 9/12/23 at 10:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if there is range of time within which medications should be administered. She stated, We should always give them within an hour before up until an hour after they are due. She stated she believed this was a facility policy. She stated this is especially important for any medication that a resident receives more than twice a day. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Medication and Treatment Orders, revealed no information related to the time frame within which medications should be administered. No further information was provided prior to exit. According to Fundamentals of Nursing, 6th Edition, 2005: [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc., page 843, All routinely ordered medications should be given within 60 minutes of the times ordered. References: (1) Potassium is a mineral that your body needs to work properly. It is a type of electrolyte. It helps your nerves to function and muscles to contract. It helps your heartbeat stay regular. It also helps move nutrients into cells and waste products out of cells. This information is taken from the website https://medlineplus.gov/potassium.html. (2) Prescription famotidine is used to treat ulcers (sores on the lining of the stomach or small intestine); gastroesophageal reflux disease (GERD, a condition in which backward flow of acid from the stomach causes heartburn and injury of the esophagus [tube that connects the mouth and stomach]); and conditions where the stomach produces too much acid. This information is taken from the website https://medlineplus.gov/druginfo/meds/a687011.html. (3) Stool softeners are used on a short-term basis to relieve constipation by people who should avoid straining during bowel movements because of heart conditions, hemorrhoids, and other problems. They work by softening stools to make them easier to pass. This information is taken from the website https://medlineplus.gov/druginfo/meds/a601113.html. (4) Albuterol is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways). This information is taken from the website https://medlineplus.gov/druginfo/meds/a682145.html. 2. For Resident #2 (R2), the facility staff failed to administer Colace (1) in a timely manner. R2 was admitted to the facility with diagnoses including multiple fractures of the leg and arm and muscle spasms. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/26/23, R2 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:28 p.m., R2 was interviewed, and stated he does not receive his medications on time. He stated he does not understand why this is, and stated he has talked to the nurses multiple times about it. A review of R2's provider's orders revealed the following order dated 8/14/23: Docusate Sodium (Colace) Capsule 100 mg (milligrams) Give one capsule by mouth two times a day for constipation. A review of R2's August and September 2023 MARs (medication administration records) revealed he received Colace more than an hour past the time it was due on the following dates and times: 8/26/23 at 9:28 a.m. (due at 6:00 a.m.); 9/1/23 at 10:20 a.m. (due at 6:00 a.m.); 9/3/23 at 10:25 a.m. (due at 6:00 a.m.); and 9/3/23 at 8:46 p.m. (due at 6:00 p.m. On 9/12/23 at 10:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if there is range of time within which medications should be administered. She stated, We should always give them within an hour before up until an hour after they are due. She stated she believed this was a facility policy. She stated this is especially important for any medication that a resident receives more than twice a day. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. No further information was provided prior to exit. NOTES (1) Stool softeners are used on a short-term basis to relieve constipation by people who should avoid straining during bowel movements because of heart conditions, hemorrhoids, and other problems. They work by softening stools to make them easier to pass. This information is taken from the website https://medlineplus.gov/druginfo/meds/a601113.html.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications in a manner to prevent significant medication errors for two of six residents in the survey sample, Residents #3 and #2. The findings include: 1. For Resident #3 (R3), the facility staff failed to administer Morphine Sulfate (1) in a timely manner. R3 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) and lung cancer that had spread to other parts of the body. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/30/23, R3 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:48 p.m., R3 was interviewed. She stated: I'm not sure I get my medicines at the right time always. They do give them to me pretty regularly. A review of R3's provider's orders revealed the following order dated 8/29/23: Morphine Sulfate Oral Solution 100 mg/ml (milligrams per milliliter) Give 0.75 ml by mouth every 6 hours for pain related to [lung cancer.] A review of R3's August and September 2023 MARs (medication administration records) revealed R3 received Morphine more than an hour past the time they were due on the following dates and times: 9/2/23 at 1:56 a.m. (due at midnight); 9/2/23 at 7:27 a.m. (due at 6:00 a.m.); 9/2/9/2/23 at 2:02 p.m. (due at 12:00 p.m.); 9/2/23 at 8:01 p.m. (due at 6:00 p.m.); 9/4/23 at 4:21 a.m. (due at midnight). A review of R3's comprehensive care plan revealed, in part: The resident has risk for experiencing episodes of pain r/t (related to) neoplasm of the lung with mets (metastasis - spreading of cancer to other parts of the body) .Administer analgesia as per orders. On 9/12/23 at 10:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if there is range of time within which medications should be administered. She stated: We should always give them within an hour before up until an hour after they are due. She stated she believed this was a facility policy. She stated this is especially important for any medication that a resident receives more than twice a day. When asked about the importance of residents receiving pain medications on time, she stated: Those are the most important. Our residents need their pain meds on time. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. A review of the facility policy, Medication and Treatment Orders, revealed no information related to the time frame within which medications should be administered. No further information was provided prior to exit. Reference: (1) Morphine is used to relieve moderate to severe pain. Morphine extended-release tablets and capsules are only used to relieve severe (around-the-clock) pain that cannot be controlled by the use of other pain medications. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682133.html. 2. For Resident #2 (R2), the facility staff failed to administer Tizanidine (1), Keflex (2), and Tylenol in a timely manner. R2 was admitted to the facility with diagnoses including multiple fractures of the leg and arm and muscle spasms. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/26/23, R2 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:28 p.m., R2 was interviewed, and stated he does not receive his medications on time. He stated he does not understand why this is, and stated he has talked to the nurses multiple times about it. He stated he has to ask for his scheduled Tylenol, and the nurses still do not administer it to him on time. R2 stated Tylenol is the only pain medicine he receives, and it is important to him to receive it on time. A review of R2's provider's orders revealed the following orders: 7/21/23 Acetaminophen Oral (Tylenol) 325 mg (milligrams) Give 3 tablets by mouth three times a day for pain. 8/27/23 Keflex Oral Capsule 500 mg Give 1 capsule by mouth three times a day for UTI. 7/22/23 Tizanidine Oral Tablet 2 mg Give 1 tablet by mouth every 8 hours for muscle spasms. A review of R2's August and September 2023 MARs (medication administration records) revealed he received the following medications more than an hour past the time they were due: Tizanidine - 8/26/23 at 9:28 a.m. (due at 8:00 a.m.); 8/26/23 at 6:52 p.m. (due at 4:00 p.m.); 9/1/23 at 10:20 a.m. (due at 8:00 a.m.); 9/1/23 at 6:28 p.m. (due at 4:00 p.m.); 9/3/23 at 2:58 a.m. (due at midnight); 9/3/23 at 8:46 p.m. (due at 4:00 p.m.) Keflex - 9/1/23 at 10:20 a.m. (due at 9:00 a.m.); 9/3/23 at 10:25 a.m. (due at 9:00 a.m.).; not given at all 9/1/23 at 9:00 p.m. Tylenol - 9/1/23 at 10:20 a.m. (due at 9:00 a.m.), 9/3/23 at 10:25 a.m. (due at 9:00 a.m.).; not given at all on 9/1/23, 9/3/23, and 9/4/23 at 9:00 p.m. A review of R2's comprehensive care plan dated 7/22/23 and revised 8/3/23 revealed, in part: The resident has acute pain r/t (related to) multiple fractures related to MVA (motor vehicle accident .Administer analgesia as per orders. On 9/12/23 at 10:03 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked if there is range of time within which medications should be administered. She stated: We should always give them within an hour before up until an hour after they are due. She stated she believed this was a facility policy. She stated this is especially important for any medication that a resident receives more than twice a day. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. No further information was provided prior to exit. References: (1) Tizanidine is used to relieve the spasms and increased muscle tone caused by multiple sclerosis (MS, a disease in which the nerves do not function properly and patients may experience weakness, numbness, loss of muscle coordination and problems with vision, speech, and bladder control), stroke, or brain or spinal injury. Tizanidine is in a class of medications called skeletal muscle relaxants. It works by slowing action in the brain and nervous system to allow the muscles to relax. This information is taken from the website https://medlineplus.gov/druginfo/meds/a601121.html. (2) Cephalexin (Keflex) is used to treat certain infections caused by bacteria such as pneumonia and other respiratory tract infections; and infections of the bone, skin, ears, , genital, and urinary tract. Cephalexin is in a class of medications called cephalosporin antibiotics. It works by killing bacteria. This information is taken from the website https://medlineplus.gov/druginfo/meds/a682733.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility staff failed to serve food at a palatable texture and appetizing temperature, on one of three facility units, the [NAME] unit. The findings include: A test tray from the [NAME] unit at breakfast on 9/12/23 contained cold, soggy toast and a lukewarm cheese omelet. On 9/12/23 at 6:50 a.m., OSM (other staff member) #2, a cook, was observed as he took temperatures of the hot breakfast foods on the tray line prior to resident meals being served. OSM #2 removed the toast from the toaster and put it in a steam table pan on the serving line. When he tested the cheese omelets, they registered a temperature of 197 degrees (Fahrenheit). On 9/12/23 at 7:51 a.m., the test tray was prepared, covered, and placed on the cart with other meals for [NAME] unit residents. The cart arrived on the unit at 7:56 a.m. On 9/12/23 at 8:08 a.m., the last resident on the [NAME] unit had been served breakfast. OSM #1 (the dining services manager) took the temperature of the omelet; the temperature was 97 degrees. The omelet tasted only lukewarm. The toast was mildly cold and soggy. OSM #1 was asked to taste both the toast and the omelet. She agreed that the toast was soggy and cold, and that the omelet was not at a palatable warm temperature. She stated: It is a long way from the kitchen to the unit. And the nursing staff passes out the tray. We never know how long that might take. A review of the facility policy, Food and Nutrition Services, revealed: Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 9/12/23 at 11:30 a.m., ASM (administrative staff member) #1 and ASM #2, the regional nurse consultant, were informed of these concerns. No further information was provided prior to exit.

Based on observation, resident interview, responsible party interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to honor a resident's right to make choices about their bathing preferences for two of 33 residents in the survey sample, Resident #47 and Resident #29. The findings include: 1. For Resident #47 (R47), the facility staff failed to provide showers as per their preference. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/24/2022, the resident was assessed as being moderately impaired for making daily decisions. Section G documented R47 being totally dependent on one staff member for bathing. On 11/15/2022 at 11:15 a.m., a telephone interview was conducted with R47's responsible party. R47's responsible party stated that showers were supposed to be given twice a week, however on most weeks R47 was only receiving a shower once a week. R47's responsible party stated that they felt that this was due to staffing and that the aides were doing the best that they could. On 11/15/2022 at 12:07 p.m., an observation was made of R47 in their room. R47 was observed dressed and sitting in a wheelchair watching television. An interview was conducted with R47; R47 was able to answer yes and no questions. When asked if they preferred to get showers, R47 stated, Yes. The comprehensive care plan for R47 dated 5/5/2022 documented in part, The resident has an ADL (activities of daily living) self-care performance deficit AEB (as evidenced by) requires extensive to total assist with ADLs; is able to feed self with supervision; SAH (subarachnoid hemorrhage) with right sided hemiparesis. Date Initiated: 05/05/2022. Revision on: 11/14/2022. Review of the ADL-Bathing documentation for 9/1/2022-9/30/2022 for R47 documented in part, ADL-Bathing. It documented one shower provided the week of 9/18/2022 - 9/25/2022. Review of the ADL-Bathing documentation for 10/1/2022-10/31/2022 for R47 documented in part, ADL-Bathing. It documented one shower provided the week of 10/23/2022-10/30/2022. Review of the clinical record failed to evidence R47 refusing showers during the dates listed above. On 11/16/2022 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that showers were provided to residents twice a week. LPN #4 stated that they kept a shower book at the nurses station which had a schedule for residents scheduled for each day on the day and evening shift. LPN #4 stated that staff were offering showers to all residents. LPN #4 stated that resident preferences were passed on to the nursing assistants in report. On 11/16/2022 at 10:39 a.m., an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 stated that showers were offered twice a week to residents. CNA #7 stated that they always asked the resident if they wanted a shower or a bath. CNA #7 stated that depending on the resident, sometimes they would take a shower and sometimes they would refuse. CNA #7 stated that they had a shower book that told them who was scheduled on what day. CNA #7 stated that if the resident refused the shower, they let the nurse know. CNA #7 stated that they documented the showers in the computer in the ADL's. On 11/16/2022 at 3:07 p.m., an interview was conducted with CNA #8. CNA #8 stated that showers were offered two times a week. CNA #8 stated that showers were always offered to residents prior to a bed bath being given. CNA #8 stated that if a resident refused the shower they notified the nurse and documented it. CNA #8 stated that R47 never refused their shower because they loved them. CNA #8 stated that R47 received their showers on the day shift normally on Tuesdays and Thursdays and they normally gave them when they were working because R47 preferred them. On 11/16/2022 at 2:55 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that they tried to staff two CNA's on R15's unit on day and evening shift. ASM #2 stated that at the minimum there should always be a nurse and a CNA on the unit. ASM #2 stated that the workload for the nurse was not as high for that unit so the expectation was for the nurse to help the CNA. ASM #2 stated that they were out on the unit each day speaking with the staff on the floor and assessing the acuity of the residents to determine the daily staffing needs. ASM #2 stated that they had received comments from staff about not being able to provide showers due to their workload and they or the assistant director of nursing had stepped in and completed the showers. On 11/16/2022 at 4:28 p.m., an interview was conducted with OSM (other staff member) #3, staffing coordinator. OSM #3 stated that they tried to staff R15's unit according to the census. OSM #3 stated that they tried to maintain one nurse and two CNA's on day and evening shift. OSM #3 stated that they communicated with the staff on the unit and learned which days were shower days to staff the unit more. On 11/17/2022 at 9:27 a.m., an interview was conducted with ASM #3, the assistant director of nursing. ASM #3 stated that there was a schedule which documented when residents were scheduled for their showers. ASM #3 stated that everyone should be offered a shower as long as they were deemed safe. The facility policy, Resident Self Determination and Participation documented in part, .1. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including: a. Daily routine, such as sleeping and waking, eating, exercise and bathing schedules; b. Personal care needs, such as bathing methods, grooming styles and dress; . The facility policy, Shower/Tub Bath documented in part, .1. Qualified nursing staff will provide a bed bath to the resident as needed. At a minimum, the resident will be offered at least 2 full baths or showers per week. 2. To the extent possible, resident preference for type and frequency of baths will be taken into consideration and honored . On 11/16/2022 at approximately 6:17 p.m., ASM #4, the interim administrator and ASM #2, the director of nursing were made aware of the concern. No further information was presented prior to exit. Complaint deficiency.2. For Resident #29 (R29), the facility staff failed to honor the resident's preference for showers. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/30/2022, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring physical help of the bathing activity with one person assisting. An interview was conducted with R29 on 11/17/2022 at 8:16 a.m. When asked if they prefer a bath, shower or bed bath, R29 stated they like a shower on their shower days. An interview was conducted with CNA (certified nursing assistant) #7 on 11/17/2022 at 8:20 a.m. When asked how she knows what type of bath/shower, R29 wants, CNA #7 stated, [R29] will tell you what they want. The resident knows their shower days and will say, shower day - shower. The September 2022 ADL (activity of daily living) document for baths documented the resident only received two showers and one whirlpool, the rest of the baths were documented as bed baths. The October 2022 ADL document documented the resident should have received eight showers. The documentation only documented four showers and four bed baths. The November 2022 ADL document documented the resident should have had five showers, it was documented the resident had one shower, two bed baths and two blanks where the resident should have received a shower. An interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, on 11/17/2022 at 9:25 a.m. When asked how a staff member knows what type of bath the resident wants, a shower, whirlpool, or bed bath, ASM #3 stated the staff should be asking the resident. Everyone should be asked if they want a shower. The facility policy, Shower/Tub Bath documented in part, POLICY: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. SPECIFIC PROCEDURES / GUIDANCE: General Guidelines - 1.Qualified nursing staff will provide a bed bath to the resident as needed. At a minimum, the resident will be offered at least 2 full baths or showers per week. 2.To the extent possible, resident preference for type and frequency of baths will be taken into consideration and honored. ASM #1, the interim administrator, and ASM #2, the director of nursing were made aware of the above concern on 11/17/2022 at 12:06 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review it was determined that the facility failed to ensure one of 33 residents were free of misappropriation of property, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to ensure they were free of misappropriation of prescribed controlled medication. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/2/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section J documented R10 receiving scheduled pain medication and having pain almost constantly. Section N documented R10 receiving opioid medications during the assessment period. On 11/16/2022 at 9:19 a.m., an observation was made of R10 in their room. R10 was observed in bed watching television. An interview was conducted with R10. R10 stated that they often had pain and the nurses administered pain medication to them. R10 stated that the nurses took very good care of them and that their pain was well controlled. R10 stated that they did not recall any times when the nurses did not respond to their pain and attempt to make them comfortable. Review of the FRI's (facility reported incidents) documented a FRI dated 8/29/2022 involving R10. The FRI documented in part, .Incident Type: Possible Resident property misappropriated. Describe incident, including location, and action: On 8/29/2022, the pharmacist informed the Director of Nursing via phone that resident [name of R10] was missing one card of 30 tablets of hydrocodone-APAP 5-325 mg (milligram). (1) Review of the FRI incident investigation dated 9/2/2022 documented in part, .Conclusion: After thorough investigation of this incident the facility can confirm that misappropriation of the resident property, 30 doses of Hydrocodone-APAP 5-325 mg. The facility cannot definitively confirm if the medication card and the narcotic count sheet was removed by [Name of LPN (licensed practical nurse) #3]. The facility had informed the [Name of staffing agency] that [Name of LPN #3] cannot return to the facility. The completed FRI documented staff statements and in-service training report dated 8/30/2022 for Narcotic documentation and destruction signed by 14 staff members. The in-service training contained the facility policy 5.2 Receipt of Interim/Stat/Emergency Deliveries. The comprehensive care plan for R10 documented in part, The resident has chronic pain r/t (related to) neuropathy. Date Initiated: 09/20/2022, Revision on: 09/20/2022. The physician orders for R10 documented in part, Hydrocodone-APAP 5-325 MG, Give 1 tablet orally two times a day related to PAIN, UNSPECIFIED. Order Date: 06/13/2022, Start Date: 06/13/2022. The eMAR (electronic medication administration record) for R10 dated 8/1/2022-8/31/2022 documented in part, Hydrocodone-APAP 5-325 MG, Give 1 tablet orally two times a day related to PAIN, UNSPECIFIED. The eMAR documented R10 receiving the medication every morning and every evening except on 8/25/2022 and 8/29/2022 morning doses. On 8/25/2022 and 8/29/2022 morning doses it documented a 9 in the administration box. The eMAR documented, Chart Codes: .9=Other/See Progress notes . The eMAR further documented a pain evaluation completed every shift. The pain assessment on 8/25/2022 and 8/29/2022 documented a pain level of zero. The progress notes for R10 documented in part, 8/25/2022 09:41 (9:41 a.m.) Note Text: Hydrocodone-APAP 5-325 MG T, Give 1 tablet orally two times a day related to PAIN, UNSPECIFIED . Med (medication) not on hand. The progress notes further documented, 8/29/2022 13:55 (1:55 p.m.) Note Text: Hydrocodone-APAP 5-325 MG T Give 1 tablet orally two times a day related to PAIN, UNSPECIFIED . Not available. The progress note dated 8/30/2022 at 3:32 p.m. documented, Note Text: Follow up note: On 09/29/2022 this nurse noted that there were no Hydrocodone/Acetaminophen medication located in the narcotic drawer. This nurse called pharmacy to inform them that the medication needed to be restocked so ensure the patient could take her medication in a timely manner. The pharmacy was unable to send the medication. This nurse noted this in the medication progress notes. Patient was made aware of this. Thus nurse will follow up with any further information when it is received. On 11/16/2022 at 8:03 a.m., ASM (administrative staff member) #2, the director of nursing, stated that LPN (licensed practical nurse) #3 and the other agency LPN who also worked on the unit 8/24/2022, no longer worked at the facility. On 11/16/2022 at 1:36 p.m., ASM #3, the assistant director of nursing, stated that the RN (registered nurse) who documented the progress note on 8/29/2022 no longer worked at the facility. On 11/16/2022 at 9:28 a.m., an interview was conducted with LPN #4. LPN #4 stated that narcotics were counted at shift change by the off going nurse and the ongoing nurse. LPN #4 stated that the two nurses went through the medication cards and matched them with the count sheets to ensure that everything matched. LPN #4 stated that if anything did not match they were not allowed to leave the building until everything matched. LPN #4 stated that when they were administering any controlled medication they kept a count of the number of pills that were left in a narcotic book which held the narcotic sheets. On 11/16/2022 at 2:55 p.m., an interview was conducted with ASM #2, director of nursing. ASM #2 stated that they had received a call from the pharmacy stating that a request had been made to refill R10's hydrocodone and that it was too early. ASM #2 stated that the pharmacy had delivered two cards of hydrocodone and two narcotic count sheets at the same time for the resident totaling 60 tablets. ASM #2 stated that after speaking with the pharmacy they advised them that R10 should have 30 more tablets at the facility so they had started an investigation into the missing hydrocodone. ASM #2 stated that the hydrocodone had been discovered to be missing on the day shift. ASM #2 stated that they had discovered that the day shift nurse who had counted the narcotics that day had not worked the day prior. ASM #2 stated that when the day shift nurse went to administer the scheduled medication to R10 there was none there so they called the pharmacy who advised that it was too soon to refill the medication. ASM #2 stated that they had interviewed the two nurses who worked the night shift prior. ASM #2 stated that LPN #3 had left a lot of room for questions and became more vague during the interview. ASM #2 stated that they had narrowed it down to the medication missing on the night shift. ASM #2 stated that they made LPN #3 a do not return with the agency and the other nurse who had worked with them just stopped coming to the facility. ASM #2 stated that the facility did not do any drug testing. ASM #2 stated that they had initiated education to the staff and implemented a new system for counting the drugs and the cards as well as a new way to receive narcotics from the pharmacy and add the sheets to the book. ASM #2 stated that they could not definitively determine that LPN #3 removed the hydrocodone and the count sheet because both LPN #3 and the nurse that worked with them that night on the other medication cart were vague on whether or not they gave the keys to the other during their break. ASM #2 stated that they had reported the FRI to the department of health professions along with the FRI investigation. On 11/17/2022 at 9:27 a.m., an interview was conducted with ASM #3, the assistant director of nursing. ASM #3 reviewed the in-service training report included in the FRI investigation for R10 dated 8/29/2022 and stated that they had conducted education for all licensed staff on 8/30/2022 on narcotic documentation and destruction. ASM #3 stated that the director of nursing did the investigation of the incident and they did the education attached to the FRI. ASM #3 stated that they reviewed the attached policies on receipt and disposal of controlled substances with the staff and reviewed the new process for counting narcotics with staff. ASM #3 stated that they educated staff that if there were more than two narcotic sheets and cards they were to label them 1 of 2 and 2 of 2. ASM #3 stated that the nurses were not allowed to leave until the count was equal and any wastes of narcotics they or the director of nursing were a part of. ASM #3 stated that they wasted all narcotics together in the medication rooms. ASM #3 stated that they had looked at every narcotic sheet in all of the narcotic books and assessed other residents but they did not have any documentation of the other residents being reviewed. On 11/17/2022 at 10:01 a.m., an interview was conducted with OSM (other staff member) #5, the human resource manager. OSM #5 stated that contracted agency staff members were trained and screened prior to working in the facility. OSM #5 stated that they had been working at the facility since May of this year and had been working to catch up files for contracted agency staff members who worked at the facility. OSM #5 stated that prior to an agency staff member coming to the facility for their first shift they received information from the agency including their background check. OSM #5 stated that contracted agency staff members received an orientation packet which contained policies at the facility and abuse, neglect and misappropriation training. OSM #5 stated that they did not have a file for LPN (licensed practical nurse) #3 and had contacted the agency on 11/16/2022 to get the requested employee documents. OSM #5 stated that they did not have any evidence of training received on abuse, neglect and misappropriation. OSM #5 provided a hire date of 8/21/2022 for LPN #3 and facility schedules documenting LPN #3 working 8/21/2022 and 8/28/2022. The facility policy Abuse revised 10/20/2022 documented in part, .At a minimum, education on abuse, neglect, and exploitation will be provided to facility staff upon hire and annually. In addition to the freedom from abuse, neglect, mistreatment of residents, misappropriation of property and exploitation requirements in 483.12, the organization will also provide training to their staff on: Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12 .Criminal record checks will be obtained in accordance with state law and/or facility policy .Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety .The facility Quality Assurance/Performance Improvement Committee will review and provide recommendation for unusual occurrences .Virginia Specific Requirements: .Criminal record checks will be obtained on all new employees within 30 days of date of hire. If contract staff is used (i.e. housekeeping, dietary, rehab, etc.) the vendor providing the contracted service will be asked to obtain criminal record checks for all staff assigned to the nursing facility and to make the criminal record check information available to the nursing facility in a timely manner upon request . On 11/17/2022 at approximately 12:05 p.m., ASM #4, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. (1) hydrocodone Hydrocodone is used to relieve severe pain. Hydrocodone is only used to treat people who are expected to need medication to relieve severe pain around-the-clock for a long time and who cannot be treated with other medications or treatments. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a614045.html

Based on staff interview, facility document review, and clinical record review it was determined that the facility failed to implement the facility abuse policy for screening staff for one of four agency staff reviewed, LPN (licensed practical nurse) #3. The findings include: The facility staff failed to implement their abuse policy for staff screening for LPN #3. During the course of a FRI (facility reported incident) review for Resident #10 (R10) regarding misappropriation of resident property, it was determined that LPN #3 did not have a background check completed prior to working at the facility. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/2/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section J documented R10 receiving scheduled pain medication and having pain almost constantly. Section N documented R10 receiving opioid medications during the assessment period. Review of the FRI's (facility reported incidents) documented a FRI dated 8/29/2022 for R10. The FRI documented in part, .Incident Type: Possible Resident property misappropriated. Describe incident, including location, and action: On 8/29/2022, the pharmacist informed the Director of Nursing via phone that resident [name of R10] was missing one card of 30 tablets of hydrocodone-APAP 5-325 mg (milligram). (1) Review of the FRI incident investigation dated 9/2/2022 documented in part, .Conclusion: After thorough investigation of this incident the facility can confirm that misappropriation of the resident property, 30 doses of Hydrocodone-APAP 5-325 mg. The facility cannot definitively confirm if the medication card and the narcotic count sheet was removed by [Name of LPN (licensed practical nurse) #3]. The facility had informed the [Name of staffing agency] that [Name of LPN #3] cannot return to the facility. On 11/16/2022 at 8:03 a.m., ASM (administrative staff member) #2, the director of nursing, stated that LPN (licensed practical nurse) #3 and the other agency LPN who also worked on the unit 8/24/2022, no longer worked at the facility. On 11/16/2022 at approximately 9:00 a.m., a request was made to ASM #4, the interim administrator, LPN #3's employee record. On 11/16/2022 at approximately 4:00 p.m., ASM #4 provided copies of documents for LPN #3 including a background search dated 11/16/2022 and license verification report dated 8/8/2022. On 11/16/2022 at 2:55 p.m., an interview was conducted with ASM #2, director of nursing. ASM #2 stated that they had received a call from the pharmacy stating that a request had been made to refill R10's hydrocodone and that it was too early. ASM #2 stated that the pharmacy had delivered two cards of hydrocodone and two narcotic count sheets at the same time for the resident totaling 60 tablets. ASM #2 stated that after speaking with the pharmacy they advised them that R10 should have 30 more tablets at the facility so they had started an investigation into the missing hydrocodone. ASM #2 stated that the hydrocodone had been discovered to be missing on the day shift. ASM #2 stated that they had discovered that the day shift nurse who had counted the narcotics that day had not worked the day prior. ASM #2 stated that when the day shift nurse went to administer the scheduled medication to R10 there was none there so they called the pharmacy who advised that it was too soon to refill the medication. ASM #2 stated that they had interviewed the two nurses who worked the night shift prior. ASM #2 stated that LPN #3 had left a lot of room for questions and became more vague during the interview. ASM #2 stated that they had narrowed it down to the medication missing on the night shift. ASM #2 stated that they made LPN #3 a do not return with the agency and the other nurse who had worked with them just stopped coming to the facility. ASM #2 stated that the facility did not do any drug testing. ASM #2 stated that they had initiated education to the staff and implemented a new system for counting the drugs and the cards as well as a new way to receive narcotics from the pharmacy and add the sheets to the book. ASM #2 stated that they could not definitively determine that LPN #3 removed the hydrocodone and the count sheet because both LPN #3 and the nurse that worked with them that night on the other medication cart were vague on whether or not they gave the keys to the other during their break. ASM #2 stated that they had reported the FRI to the department of health professions along with the FRI investigation. On 11/17/2022 at 10:01 a.m., an interview was conducted with OSM (other staff member) #5, the human resource manager. OSM #5 stated that contracted agency staff members were trained and screened prior to working in the facility. OSM #5 stated that they had been working at the facility since May of this year and had been working to catch up files for contracted agency staff members who worked at the facility. OSM #5 stated that prior to an agency staff member coming to the facility for their first shift they received information from the agency including their background check. OSM #5 stated that they did not have a file for LPN (licensed practical nurse) #3 and had contacted the agency on 11/16/2022 to get the requested employee documents. OSM #5 stated that they did not have any evidence of a background check completed prior to 11/16/2022. OSM #5 provided a hire date of 8/21/2022 for LPN #3 and facility schedules documenting LPN #3 working 8/21/2022 and 8/28/2022. On 11/17/2022 at approximately 10:30 a.m., OSM #5 provided page 6 of the employee handbook and stated that they followed the procedure documented as their policy. It documented in part, .3.7 Background and Criminal History; All newly hired employees will be subject to a background and criminal history check as required by the applicable laws. This will occur on a post-offer, pre-employment basis, as state law requires and upon yearly evaluations. Unsatisfactory reports may result in rescinding an employment offer or termination of employment . The facility policy Abuse revised 10/20/2022 documented in part, .Criminal record checks will be obtained in accordance with state law and/or facility policy .Virginia Specific Requirements: .Criminal record checks will be obtained on all new employees within 30 days of date of hire. If contract staff is used (i.e. housekeeping, dietary, rehab, etc.) the vendor providing the contracted service will be asked to obtain criminal record checks for all staff assigned to the nursing facility and to make the criminal record check information available to the nursing facility in a timely manner upon request . On 11/17/2022 at approximately 12:05 p.m., ASM #4, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. (1) hydrocodone Hydrocodone is used to relieve severe pain. Hydrocodone is only used to treat people who are expected to need medication to relieve severe pain around-the-clock for a long time and who cannot be treated with other medications or treatments. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a614045.html

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 33 residents in the survey sample, Resident #206. The findings include: The facility staff failed to review and revise Resident #206's (R206) comprehensive care plan for the use of an incentive spirometer. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R206's comprehensive care plan revised on 11/9/22 failed to reveal documented information regarding an incentive spirometer. On 11/15/22 at 9:36 a.m., R206 was observed sitting in a wheelchair in the bedroom. An incentive spirometer was on the resident's over bed table. An interview was conducted with R206. R206 stated they use the incentive spirometer every two hours. On 11/16/22 at 3:26 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the purpose of the care plan is a plan of care for all staff to see what the goals are and interventions in place. LPN #5 stated a resident's care plan should be reviewed and revised to include an incentive spirometer as an intervention. On 11/16/22 at 6:19 p.m., ASM (administrative staff member) #4, the interim administrator and ASM #2, the director of nursing were made aware of the above concern. The facility policy titled, Care Planning - Comprehensive Person-Centered documented, 11. Each resident's comprehensive care plan will describe the following: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain weights as ordered by the physician, for one of 33 residents in the survey sample, Resident #22. The findings include: The facility staff failed to follow physician orders for initial admission weights ordered x 3 days, and weekly weight x 4 for Resident #22. Resident #22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CAD (coronary artery disease), hypertension, dementia, and anxiety. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 8/22/22, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan with a revision date of 8/16/22 did not include a concern with weights. A review of the physician orders dated 8/15/22, revealed, Daily Weight x3 days, Weekly Weight x4 weeks, then monthly one time a day for Assessment for 3 Days. Per physician orders, weights should have been obtained on 8/15, 8/16, 8/17, 8/22, 8/29, 9/5, 9/12, 10/10 and 11/14/22. A review of weights showed weights were obtained on 8/25, 9/8, 10/12, 10/23 and 11/14. No weight loss was identified. An interview was conducted on 11/15/22 at 8:03 AM with LPN (licensed practical nurse) #1. When asked the process for obtaining weekly weights, LPN #1 stated, weekly weights are on the assignment for the CNA to obtain. When asked if the physician ordered weights are not done, are the physician orders followed, LPN #1 stated, no, they are not. An interview was conducted on 11/15/22 at 4:20 PM, with CNA #6. When asked who obtains weights, CNA #6 stated, the CNAs get the weights, they are on our assignment. When asked when weights are obtained, CNA #6 stated, they are usually obtained on day shift and sometimes on evening shift. On 11/15/22 at 5:45 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Conformity with Laws and Professional Standards policy with no date, revealed, Our facility operates and provides services in compliance with current federal, state and local laws, regulations, codes and professional standards of practice that apply to our facility and types of services provided. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #22, the facility staff failed to provide ADL (activities of daily living) care, specifically incontinence care, for a dependent resident. Resident #22 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CAD (coronary artery disease), hypertension, dementia, and anxiety. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 8/22/22, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing and hygiene; total dependence for bathing and supervision for eating. A review of the comprehensive care plan with a revision date of 8/16/22, revealed, FOCUS: Resident has an ADL self-care performance deficit, requires assist with ADLs. INTERVENTIONS: .Resident requires assistance with bathing, dressing and toileting. Supervision with meals. Physical assist as needed. Encourage resident to use bell to call for assistance. Encourage resident to participate to the fullest extent possible with each interaction. A review of Resident #22's September, October and November 2022 ADL (activities of daily living) record revealed that the resident was incontinent of bladder on each day/evening and night shift. An interview was conducted on 11/15/22 at 8:45 AM with CNA #1. When asked about staffing, CNA #1 stated, it is worse now than when we were in full COVID mode. I have 16 residents to care for today (3 CNAs with 58 residents). I cannot care for them with bathing, incontinence care, feeding, particularly when they were short on night shift (2 CNAs for 58 residents) and they could not keep up with their care either. When asked about the frequency of incontinence care, CNA #1, stated, it is supposed to be every two hours, when we have 3 CNAs, we can get it done 2-3 times a shift. When asked if the documentation under bladder incontinence on the ADL form indicates that incontinence care was provided every two hours during her shift, CNA #1 stated, no, it does not mean we did it every two hours. On 11/15/22 at 9:00 AM, an in-person interview was conducted in Resident #22's room with the resident and Resident #22's RP (responsible party). The RP stated, look at how she is, pulled back the blanket and Resident #22 was naked except for a heavy, full urine saturated adult brief. Resident #22 stated, put the blanket back over me. When Resident #22 was asked when she was changed last, she stated, Sometime during the night. I am wet and cold now. CNA (certified nursing assistant) #1, entered the room, Resident #22's RP asked the CNA, when did you last change my mother? CNA #1 stated, She has not been changed since I started my shift. I was trying to get the residents their breakfast and then feed the residents. I was going to start incontinence rounds next. An interview was conducted on 11/15/22 at 4:20 PM, with CNA #6. When asked the frequency of incontinence care, CNA #6 stated, it is every two hours. When asked if she is able to provide incontinence care every two hours, CNA #6 stated, it depends on staffing. When we have 15 residents or more, no we cannot provide incontinence care that frequently. When asked if the documentation under bladder incontinence on the ADL form indicates that incontinence care was provided every two hours during her shift, CNA #6 stated, no, it does not mean we did it every two hours, it means we did it at least once that shift. On 11/15/22 at 5:45 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Activities of Daily Living policy with no date, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of living (ADLs). Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. No further information was provided prior to exit. Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care for two of 33 residents in the survey sample, Residents #61 and #22. The findings include: 1. The facility staff failed to assist Resident #61 (R61) with eating on 11/2/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/27/22, the resident scored 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. Section G coded R61 as requiring extensive assistance of one staff with eating. An occupational therapy note dated 6/15/21 documented, Pt. (Patient) was self feeding when OTR/L (occupational therapy employee) arrived into room, taking tray to her mouth and trying to pour it in, getting food on lap. OTR/L provided pt. with a towel to wipe her clothing off/protect it from getting more food on it and provided her with her glasses so she could see the tray better. OTR/L loaded fork with greens and fed it to patient, again with beans/ham with a spoon and also fed it to patient. OTR/L then loaded the spoon and handed it to patient, she brought it to her mouth. Pt. then demonstrated ability to self feed multiple times with Mod (moderate) I to S/SBA (supervision/stand-by assistance). An occupational therapy Discharge summary dated [DATE] documented, Eating= Partial/moderate assistance. R61's comprehensive care plan dated 6/13/22 documented, (R61) has an ADL (activities of daily living) self-care performance deficit. Interventions: Physical assistance as needed with ADLs. A nurse's note dated 11/2/22 documented, Resident brought from dining room with oatmeal on shirt. No injuries noted at this time. Clothes changed and placed in Meaningful Life program. A facility report dated 11/9/22 documented in part, TIMELINE OF EVENTS: On 11/02/2022 at about 8am, (R61) was in the [NAME] dining. (R61) was served oatmeal in a bowl, cranberry juice in a plastic cup and toast and eggs on a plate by (OSM [other staff member] #9), dietary aide. While serving other residents in the dining room, (OSM #9) noticed that (R61) had spilled oatmeal on (the resident's) right arm, leg, lap and wheelchair . On 11/16/22 at 9:52 a.m., an interview was conducted with OSM #9, dietary aide. OSM #9 stated that on 11/2/22 she was serving breakfast in the dining room and she was the only employee in the room. OSM #9 stated that usually there is nursing staff present in the dining room during meals and she did not know why none were present during breakfast on 11/2/22. OSM #9 stated she served R61 breakfast then continued serving other residents. OSM #9 stated she went back to R61 and the resident had spilled oatmeal on the resident's body and wheelchair. OSM #9 stated she immediately got R61's CNA and the CNA immediately removed R61 from the dining room. On 11/16/22 at 10:38 a.m., an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 stated R61 requires assistance with eating. CNA #7 stated R61 can feed self sandwiches and finger foods but must be physically assisted with liquids, soups and oatmeal. CNA #7 stated R61's arms are contracted and the resident can't always bring the spoon up right to the resident's mouth. CNA #7 stated R61 spills a lot of food while using utensils. CNA #7 stated she thought there was no nursing staff in the dining room during breakfast on 11/2/22 but she did not know why. CNA #7 stated that on 11/2/22, she was assisting another resident with care when OSM #9 came to her. CNA #7 stated OSM #9 told her R61 spilled oatmeal on the resident's body so she finished care with the other resident and went to the dining room to get R61. CNA #7 stated R61 had oatmeal on clothing covering the resident's right lower arm and right leg so she took R61 to the bed room and changed the resident's clothes. On 11/16/22 at 3:13 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated nursing staff is supposed to be present in the dining room to supervise and assist residents with meals. ASM #2 stated she prefers one nurse and two CNAs to be in the dining room during meals but this varies depending on how many residents are present and how many residents need assistance. On 11/16/22 at 6:19 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Assistance with Meals documented, Dining Room Residents: 1. Facility staff will serve resident trays and will help residents who require assistance with eating. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. No further information was presented prior to exit.

Based on resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide incontinence care in a timely manner for one of 33 residents in the survey sample, Resident #51 (R51). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/23/2022, the resident was coded as having no short or long term memory difficulties. In Section H - Bladder and Bowel, the resident was coded as always being incontinent of both bowel and bladder. On 11/15/2022 at 9:04 a.m. R51 stated, We don't get changed. R51 stated they were changes at 6:30 a.m. and not since then. R51 stated, It's now 9:00 a.m. and I have moved my bowels. The call bell was initiated by the resident. At 9:06 a.m. a staff member entered the room and then exited without changing the resident. The staff member went into the next room. At 9:26 a.m. the resident stated they still had not been changed. The resident was changed at 10:00 a.m. CNA (certified nursing assistant) #14, the restorative aide. The comprehensive care plan dated, 5/11/2022 and revised on 11/14/2022, documented in part, Focus: [R51] has an ADL self care performance deficit AEB (as exhibited by) need for assistance with all ADLs. The Interventions documented in part, Physical assist as needed for all ADLs. There was no documentation related to incontinence or bowel and bladder. An interview was conducted with CNA #14 on 11/15/2022 at 2:45 p.m. When asked if she assisted R51 that morning, CNA #14 stated she gave the resident a bath and applied lotion on their back, put new sheets on the bed. and stated it was not her usual assignment, but when she sees a call light on, she goes in and see what the resident needs. [R51] told me they wanted a bath and had soiled themselves. CNA #14 stated that since the resident had a BM (bowel movement) and it was all in the front of the resident in the front of the brief. she decided to give her a bath. On 11/15/2022 at 4:23 p.m. an interview was conducted with CNA #1, the CNA assigned to R51. When asked why R51 had not been changed since 6:30 a.m., CNA #1 stated there was an incident with the resident in the next room, she had to handle that before she did anything else. CNA #1 stated she was assigned 16 residents that day. When asked if that was normal, CNA #1 stated it's usually two aides and they usually pull from another floor. CNA #1 stated she got four residents up, she got to work at 7:30 a.m.; she hit the floor running and stated the assignment she had is a very heavy assignment. An interview was conducted with LPN (licensed practical nurse) #4, the unit manager, on 11/16/2022 at 10:13 a.m. When asked how often incontinence care is provided to residents, LPN #4 stated it should be every two hours unless the resident asks for it sooner. LPN #4 was informed of R51 waiting to be changed on 11/15/2022. LPN #4 stated she would normally change a resident if they request. [R51] will holler out to her in the hallway to come see her. LPN #4 stated the facility staff do not change residents during meals; she is trying to get a happy medium, if trays are out, we don't do incontinence care, we let them eat and then start changing everyone. The trays come on the floor at 7:30 a.m. and are picked up at 8:30 a.m. Unless someone tells them, they are sitting in stool, we don't know. When asked why it's not good to sit wet or sit in stool, LPN #4 stated, sitting in their own stool can lead to UTIs (urinary track infections). The facility policy, Incontinence documented in part, Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. ASM (administrative staff member) #2, the director of nursing, and ASM #4, the interim administrator, were made aware of the above concern on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit.

2. For Resident #98 (R98), the facility staff failed to obtain a physician's order for the use of an incentive spirometer and failed to store the incentive spirometer in a sanitary manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/20/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of Review of R98's November 2022 physician's orders failed to reveal a physician's order for an incentive spirometer. R98's comprehensive care plan dated 10/16/22 documented, The resident has altered respiratory status/difficulty breathing r/t (related to) respiratory failure, COPD (chronic obstructive pulmonary disease), recent aspiration. Administer medication/puffers as ordered. On 11/15/22 at 9:12 a.m., R98 was observed sitting in a wheelchair in the bedroom. An incentive spirometer was on the resident's over bed table. The incentive spirometer mouth piece was uncovered and exposed to air. On 11/16/22 at 10:11 a.m., the incentive spirometer remained uncovered on R98's over bed table. At this time, an interview was conducted with R98. R98 stated they try to use the incentive spirometer ten times every hour and staff had not offered a covering for the device. On 11/16/22 at 3:26 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated residents should have a physician's order for the use of an incentive spirometer so the nurses can encourage use, make sure residents are using the device properly and make sure the device is within residents' reach. LPN #5 stated an incentive spirometer should be stored in a Ziploc bag for sanitation and cleanliness. On 11/16/22 at 6:19 p.m., ASM (administrative staff member) #4, the interim administrator and ASM #2, the director of nursing were made aware of the above concern. The facility policy titled, Incentive Spirometry documented, To have patient perform sustained maximal inspiration without added resistance or positive pressure while presenting visual feedback of effort. Incentive Spirometry can be instructed/administered by an Respiratory Care Practitioner upon written physician's order. The policy failed to document information regarding incentive spirometer storage. No further information was presented prior to exit. 3. For Resident #206's (R206), the facility staff failed to obtain a physician's order the use of an incentive spirometer and failed to store the incentive spirometer in a sanitary manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of R206's November 2022 physician's orders failed to reveal a physician's order for an incentive spirometer. R206's comprehensive care plan revised on 11/9/22 failed to document information regarding an incentive spirometer. On 11/15/22 at 9:36 a.m., R206 was observed sitting in a wheelchair in the bed room. An incentive spirometer was on the resident's over bed table. The incentive spirometer mouth piece was uncovered, touching the over bed table and exposed to air. At that time, an interview was conducted with R206. R206 stated they use the incentive spirometer every two hours and staff had not provided a covering for the device. On 11/16/22 at 10:03 a.m., R206's incentive spirometer remained on the over bed table, with the mouth piece uncovered and touching the over bed table. On 11/16/22 at 3:26 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated residents should have a physician's order for the use of an incentive spirometer so the nurses can encourage use, make sure residents are using the device properly and make sure the device is within residents' reach. LPN #5 stated an incentive spirometer should be stored in a Ziploc back for sanitation and cleanliness. On 11/16/22 at 6:19 p.m., ASM (administrative staff member) #4, the interim administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice for three of 33 residents in the survey sample, Residents #53, #98 and #206. The findings include: 1. For Resident #53 (R53), the facility staff failed to obtain a physician order for the use of oxygen. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with the assessment reference date of 10/15/2022, the resident was coded as having no short or long term memory issues. In Section O - Special Treatment, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility. R53 was observed on 11/15/2022 at approximately 8:45 a.m. in their bed with oxygen on 2 LPM (liters per minute) via a nasal cannula. A second observation was made on 11/15/2022 at 11:53 a.m. R53 was in the wheelchair with the oxygen on at 2 LPM via a nasal cannula with a portable tank secured to the wheelchair. Review of the physician orders failed to evidence a physician order for the use of oxygen. Review of the comprehensive care plan, last updated 11/14/2022, failed to evidence documentation of the use of oxygen for R53. An interview was conducted with LPN (licensed practical nurse) #4 on 11/16/2022 at 10:20 a.m. LPN #4 was asked to review R53's physician orders. When asked if she saw an order for the use of oxygen, LPN #4 stated, no. When asked if there needed to be a physician order for the use of oxygen, LPN #4 stated, yes and she didn't know why there wasn't an order. The facility policy, Oxygen Administration, documented in part, POLICY: The purpose of this procedure is to provide guidelines for safe oxygen administration. SPECIFIC PROCEDURES / GUIDANCE: Preparation -1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. ASM (administrative staff member) #4, the interim administrator, and ASM #2, the director of nursing, were made aware of the above concern on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #20 (R20), the facility failed to evidence a consent and a bed rail assessment indicating the need for bed rails while they were in use. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/25/2022, the resident was assessed as being moderately impaired for making daily decisions. On 11/15/2022 at 9:20 a.m., an observation of R20 was made in their room. R20 was observed lying in bed asleep with bilateral upper half bed rails in place. Additional observations of R20 on 11/15/2022 at 11:23 a.m., 11/15/2022 at 4:04 p.m. and 11/16/2022 at 8:45 a.m., revealed R20 in bed with bilateral upper half bed rails in place. The comprehensive care plan for R20 failed to evidence documentation of the use of bed rails. The physician orders for R20 failed to evidence documentation for the use of bed rails. The side rail and entrapment risk assessment dated [DATE] for R20 documented in part, .Is the resident dependent in bed mobility? Yes .Will the use of side rails optimize resident independence in bed mobility and transfer? No .Can the resident demonstrate use of the side rails, independently or with little prompting, for bed mobility? No .Has the resident or resident representative requested use of side rails? No .Will the use of side rails during care provided by staff optimize resident safety and security? No .The following side rail use is recommended. No side rails indicated at this time .Other recommendations: Resident is unable to raise and lower side rails independently . On 11/16/2022 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated they were not sure why R20 had bed rails. LPN #4 stated that R20 could not pull themselves up and could not hold onto them during care. LPN #4 reviewed the bed rail assessment for R20 and stated that it appeared that R20 was not supposed to have the bed rails on the bed. On 11/16/2022 at 1:36 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing. ASM #3 stated that they completed a bed rail safety assessment to ensure that they were safe for the resident to use them. ASM #3 stated that they assessed whether the resident was able to release the bed rail. ASM #3 stated that they had recently made changes to their process for bed rails. ASM #3 stated that when they evaluated a resident for bed rails they would see if the resident was able to release the bed rail, watch the resident roll in the bed to see if they were able to hold onto the mattress or bed frame and see how close to the edge of the bed they got when rolling from side to side. The facility policy Bed Rail Risk and Safety documented in part, .This organization will take measures to develop and implement a strategy to minimize the possibility of resident entrapment and or injury while using bed rails. This will include an evaluation of residents who have a need for or desire to use bed rails and that may have characteristics that place them at special risk for entrapment .1. Any resident being considered for using a bed with bed rail(s) is evaluated by the facility's interdisciplinary team to determine whether the resident's functional status and bed mobility is improved through the use of bed rail(s), to identify any bed rail that might constitute physical restraint, and to identify individual characteristics that may increase the risk of entrapment by bed rails or mattress . On 11/16/2022 at 6:17 p.m., ASM #4, the interim administrator and ASM #2, the director of nursing were made aware of the concern. No further information was presented prior to exit. Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement bed rail requirements for two of 33 residents in the survey sample, Residents #68 and #20. The findings include: 1. The facility staff failed to review the risks and benefits of the use of bed rails with Resident #68 (R68) (and/or the resident's representative) and failed obtain informed consent. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/13/22, R68's cognitive skills for daily decision making were coded as moderately impaired. A review of R68's clinical record revealed a side rail (bed rail) and entrapment risk assessment dated [DATE] that documented the use of side rails during care provided by staff would optimize resident safety and security, and the use of 1/2 upper rails was recommended. Further review of R68's clinical record failed to reveal documentation that the facility staff reviewed the risks and benefits of bed rails with R68 (and/or the resident's representative) and obtained informed consent. On 11/15/22 at 8:47 a.m. and 11/16/22 at 10:08 a.m., R68 was observed lying in bed with bilateral 1/4 bed rails in the upright position. On 11/16/22 at 3:26 p.m., an interview was conducted with LPN (licensed practical nurse) #5 (the nurse who completed the side rail assessment). LPN #5 stated she did not review the risks and benefits of bed rails and obtain informed consent from R68 or the resident's representative. LPN #5 stated the unit manager may have done this. On 11/17/22 at 9:19 a.m., an interview was conducted with RN (registered nurse) #4, R68's unit manager and ASM (administrative staff member) #3, the assistant director of nursing. RN #4 and ASM #3 stated they had not reviewed the risks and benefits of bed rails and obtain informed consent from R68 or the resident's representative. ASM #3 stated ASM #2, the director of nursing may have done this. On 11/17/22 at 10:24 a.m., an interview was conducted with ASM #2. ASM #2 stated she had not reviewed the risks and benefits of bed rails and obtain informed consent from R68 or the resident's representative. On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Bed Rail Risk and Safety documented, 3. If the resident's evaluation identifies him or her as appropriate for the use of bed rail(s), the following procedures will be followed: a. Educate the resident/resident representative on the risks and obtain consent for use. i. The resident and/or resident representative's consent for use of the bed rails will be documented in the medical record. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident observation, facility document review and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet resident needs for one of 33 residents, Resident #22. The findings include: The facility staff failed to provide sufficient staffing to meet resident needs. A request was made during the entrance conference on 11/14/22 at approximately 6:45 PM to ASM (administrative staff member) #2, the director of nursing to provide as worked staffing schedules from 10/14/22-11/14/22. When asked during the entrance conference if there were any staffing waivers, ASM #2 stated, No, there are no waivers. As a part of the sufficient staffing facility task and a complaint investigation the as worked staffing sheets for 10/14/22-11/14/22 sheets for [NAME] Unit were reviewed. [NAME] Unit has 60 available beds with 58 beds occupied during survey. A review of the [NAME] Unit as worked nursing schedule for 10/14/22-11/14/22 revealed, 2 CNAs (certified nursing assistants) scheduled on day shift: 10/21, evening shift: 10/11, 10/13, 10/16, 10/17, 10/29, 10/30, 11/2, 11/6, 11/13 and night shift: 10/10, 10/11, 10/14, 10/16, 10/22, 11/2, 11/12, 11/13 and 11/14/22. Ratios on these dates were approximately 24 residents to one CNA. A review of the [NAME] Unit has worked nursing schedule for 10/14/22-11/14/22 revealed, 3 CNA (certified nursing assistant) scheduled on day shift: 10/10, 10/11, 10/17, 10/22, 10/24, 10/29, 10/30, 11/3, 11/4, 11/7, 11/11, 11/12, 11/13 and 11/14, evening shift: 10/10, 10/12, 10/15, 10/19, 10/20, 10/21, 10/22, 10/23, 10/25, 10/27, 10/29, 11/1, 11/3, 11/4, 11/7, 11/9, 11/10, 11/11, 11/12 and night shift: 10/12, 10/13, 10/15, 10/17, 10/19, 10/20, 10/21, 10/23, 10/27, 10/28, 10/29, 11/3, 11/4, 11/7, 11/8, 11/9, 11/10, and 11/11/22. Ratios on these dates were approximately 16 residents to one CNA. An interview was conducted at 8:45 AM with CNA #1. When asked about staffing, CNA #1 stated, it is worse now then when we were in full COVID mode. I have 16 residents to care for today (3 CNAs with 58 residents). I cannot care for them with bathing, incontinence care, feeding, particularly when they were short on night shift (2 CNAs for 58 residents) and they could not keep up with their care either. When asked what the usual staffing numbers are, CNA #1 stated, a lot of times we have 3 CNAs, when we should have 4 at least. Overtime is not approved until that day, but they will use agency staff. Some of us have children and have to plan ahead for childcare to work the overtime. On 11/15/22 at 9:00 AM, an interview was conducted in Resident #22's room with the resident and Resident #22's RP, (responsible party). The RP stated, look at how she is, pulled back blanket and Resident #22 was naked except for heavy, full adult brief. Resident #22 stated, put the blanket back over me. When Resident #22 was asked when she was changed last, she stated, Sometime during the night. I am wet and cold now. CNA (certified nursing assistant) #1, entered the room, Resident #22's daughter asked the CNA, when did you last change my mother. CNA #1 stated, She has not been changed since I started my shift. I was trying to get the residents their breakfast and then feed the residents. I was going to start incontinence rounds next. An interview was conducted on 11/15/22 at 2:43 PM, with OSM, #3, the scheduling coordinator. When asked what the staffing pattern is for each unit, OSM #3 stated, [NAME] has 2 RN (registered nurses) and 1 CNA (certified nursing assistant) on days/evenings and 1 RN and 2 CNAs on nights. Grace has 1 RN and 2 CNAs on days/evenings and 1 RN and 1 CNA on nights. [NAME] has 2 RNs and 4 CNAs on days/evenings and 1 RN and 3 CNAs on nights. When asked how staffing vacancies are filled, OSM #3 stated, We send out the daily open shifts. I send out a week or two ahead. Overtime is approved. We have agency fill in and we pull staff between Grace and [NAME] units. We have hired some CNAs and they are starting this coming week. When asked if she was aware that the facility triggered for staffing issues in the third quarter of 2022, OSM #3 stated, No, I was not aware of that. An interview was conducted on 11/15/22 at 10:15 AM with ASM #2, the director of nursing. When asked about the staffing on [NAME] unit with 16 residents to 1 CNA, ASM #2 stated, we also have restorative aides. When asked if the restorative aides have an assignment, ASM #2 stated, no, they help out. On 11/15/22 at 5:45 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility's Facility Assessment dated 9/2022, revealed, Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Staff direct care staff: [NAME]- LPN (licensed practical nurses) 1:30 ratio days/evenings, 1:60 ratio on nights; CNAs 1:10 ratio days/evenings, 1:15 on nights. According to the facility's Staffing policy with no date, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and the facility assessment. No further information was provided prior to exit.

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to maintain an effective training program for two of 5 employee reviews. The findings include: The facility staff failed to train LPN (licensed practical nurse) #8 and CNA (certified nursing assistant) #11 regarding the new electronic medical record system. A complaint submitted to the state agency on 6/29/22 alleged concern over the amount of time employees received regarding the new electronic medical record system. The facility transitioned to a new electronic medical record system on 6/15/22. A review of CNA and licensed nurse training/orientation checklists revealed CNAs and nurses were supposed to be trained regarding the new electronic medical record system. A review of five employee records failed to reveal evidence that LPN #8 (hired on 6/6/20 and last worked on 11/10/22) and CNA #11 (hired on 9/3/21 and last worked on 10/21/22) received training regarding the new electronic medical record system. On 11/16/22 at 2:55 p.m., an interview was conducted with ASM (administrative staff member) #4, the interim administrator. ASM #4 stated all CNAs and nurses are supposed to receive training regarding the electronic medical record system before they work so they can be prepared to document. On 11/16/22 at 6:19 p.m., ASM #4 and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. Complaint deficiency.

4. For Resident #15 (R15), the facility staff failed to honor a resident's preferences for bed rails to maintain their level of ADL (activities of daily living) self-performance and promote their sense of self-determination and independence. R15 used the bed rails on their bed to increase their ADL self-performance with staff assistance in transferring and bed mobility and requested their use however they were removed from the bed causing R15 to require more physical assistance from staff when transferring to the recliner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/30/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R15 requiring extensive assistance of two or more persons for bed mobility, one person for transfers and limited assistance of one person for walking in the room. Section G further documented R15 using a walker and a wheelchair. The previous quarterly MDS with an ARD of 8/10/2022 documented R15 requiring limited assistance of two or more persons for bed mobility, one person for transfers and limited assistance of one person for walking in the room. On 10/15/2022 at 11:30 a.m., an interview was conducted with R15 in their room. R15 was observed sitting in a recliner in their room. R15 stated that they had bed rails on their bed until a couple of weeks ago when someone came in and took them off. R15 stated that they were told that there was a state regulation that said that no one could have them. R15 stated that they used the bed rails every day prior to them being removed and wanted them back. R15 stated that they used them in bed when turning and repositioning and when transferring out of bed they used the right bed rail to hold onto to push themselves up. R15 stated that now they were trying to use the arm of the recliner and it was further from the bed and much lower than the bed rail was. R15 stated that it made their transfer much harder for them now. The side rail and entrapment risk assessment for R15 dated 11/1/2022 documented in part, .Will the use of side rails optimize resident independence in bed mobility and transfer? Yes. Explain if Yes. Resident pulls on side rail to assist when sitting up or turning. Can the resident demonstrate use of the side rails, independently or with little prompting, for bed mobility? Yes .Has the resident or resident representative requested use of side rails? Yes .Will the use of side rails during care provided by staff optimize resident safety and security? No .Has the bed inspection been completed and demonstrated that the bed is safe functionally and rails and mattress do not create risk for entrapment? Yes. Other alternatives considered/trialed prior to side rails: Low Bed .No side rails indicated at this time .Other recommendations: Resident unable to raise and lower side rails independently .The resident has an ADL self-care performance deficit. Intervention: Physical assist as needed with ADL's. Encourage the resident to use the bell to call for assistance. The ADL-Transferring documentation for R15 was reviewed from 10/20/2022-11/16/2022. It documented in part, Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). The documentation showed R15 not participating or requiring two staff members to complete the task on two days. The documentation showed R15 being independent or staff providing less than 1/2 effort needed to complete the task on all other days. The ADL-Bed Mobility documentation for R15 was reviewed from 10/20/2022-11/16/2022. It documented in part, Bed Mobility: Support Provided- How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The documentation showed R15 requiring no assistance, setup help only or one person physical assistance each day during the time frame reviewed. The comprehensive care plan for R15 dated 11/01/2022 documented in part, The resident has an ADL self-care performance deficit Date Initiated: 11/01/2022. Revision on: 11/01/2022. Under Interventions it documented in part, Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Date Initiated: 05/04/2022. On 11/15/2022 at 1:06 p.m., an interview was conducted with OSM (other staff member) #4, long term care ombudsman. OSM #4 stated that they had received multiple calls from residents and family members regarding the bed rails being removed from residents beds. OSM #4 stated that they had been told that maintenance had removed all of the bed rails about two or three weeks ago. OSM #4 stated that they were told that there were new regulations and the facility had to be restraint free so they had removed all of the bed rails and go through the steps to see if the residents needed the bed rails. OSM #4 stated that they had met with the residents and the administrative staff about this concern but had no resolution at the current time. On 11/16/2022 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that they were told that bed rails were a restraint if the resident could not put them up or down themselves and they were a safety hazard. LPN #4 stated that they were told by the director of nursing that bed rails were not necessary and were a safety hazard. LPN #4 stated that they had tried to put a bed rail up and down when in a bed and they were unable to do it themselves. On 11/16/2022 at 9:34 a.m., an interview was conducted with OSM #6, PTA (physical therapy assistant), therapy program manager. OSM #6 stated that when the facility first started removing all of the residents bed rails they were involved and would assess the residents mobility to see if it would be decreased from removing the bed rails. OSM #6 stated that they would assess to see if the resident could position themselves without the bed rails. OSM #6 stated that if the resident was high functioning and not using the bed rails or not capable of using them they were removed. When asked about residents who used the bed rails for turning who had them removed, OSM #6 stated, If they used them for turning we would make sure staff would be in there to turn them, they would go to a two person assist. OSM #6 stated that they were told that the resident needed to be able to raise and lower their bed rail to be able to keep it. When asked if having to have staff physically turn them or becoming a two person assist was promoting the residents highest practicable level of well-being, OSM #6 stated that it was not. OSM #6 stated that they were actively working with nursing to provide residents with alternative means and some of the residents were able to use the side of the mattress to hold onto. When asked if having to have staff physically turn them or becoming a two person assist was a decline in function, OSM #6 stated, Yes. OSM #6 stated that the bed rail removal decision was made by the director of nursing and the previous administrator. On 11/16/2022 at approximately 12:30 p.m., OSM #6 provided a PT (physical therapy) discharge summary for R15 dated 9/15/2022 and stated that bed rails were not used at the time R15 was in therapy. OSM #6 stated that R15 was able to perform bed mobility with supervision. The PT discharge summary documented in part, .Skilled interventions Provided: Skilled treatment interventions included instructing and training patient in positioning maneuvers, strength training, proper body mechanics, safe transfer techniques and gait training with safe use of RW (rollator walker) in order to facilitate functional mobility . On 11/16/2022 at 1:04 p.m., an interview was conducted with OSM #2, the director of maintenance. OSM #2 stated that the bed rails were removed around the beginning of November. OSM #2 stated that as far as they knew there was an inservice from the corporate office which advised that if the patient could not raise and lower the bed rail themselves it was considered a restraint. OSM #2 stated that they thought there were about three residents in the building that were able to do this. On 11/16/2022 at 1:36 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing. ASM #3 stated that if a resident wanted or needed bed rails they assessed the resident for use. ASM #3 stated that they completed a bed rail safety assessment to ensure that they were safe for the resident to use them. ASM #3 stated that they assessed whether the resident was able to release the bed rail. ASM #3 stated that whether the resident could raise and lower the bed rail did not determine if they were able to have them. ASM #3 stated that if there was a request from the physician, therapy, the resident or the family they would evaluate the resident for them. ASM #3 stated that all of the bed rails had been removed and if they had a request for them from staff or therapy they would go back and reassess the resident. ASM #3 stated that they had recently made changes to their process for bed rails. ASM #3 stated that when they evaluated a resident for bed rails they would see if the resident was able to release the bed rail, watch the resident roll in the bed to see if they were able to hold onto the mattress or bed frame and see how close to the edge of the bed they got when rolling from side to side. ASM #3 stated that a lot of the residents who had their bed rails removed used them for getting in and out of bed and turning in bed. ASM #3 stated that residents that they assessed stating that the bed rail would optimize safety and security were referred back to the director of nursing who assessed the resident also. ASM #3 stated that therapy was going in with them and helping them with adaptive devices to use instead of the bed rails. When asked about R15's bed rails, ASM #3 stated that they had spoken to all residents and explained that they were doing an assessment to determine if the bed rails were needed. ASM #3 stated that R15 never mentioned to them that they used the bed rails and that they used the arm of the recliner now. On 11/16/2022 at 2:36 p.m., an interview was conducted with ASM #2, director of nursing. ASM #2 stated that for a resident to have bed rails they had to be able to raise and lower them independently. ASM #2 stated that this was part of the CMS (Centers for Medicare and Medicaid Services) regulation. ASM #2 stated that they had removed the bed rails in the facility recently because the residents were unable to raise and lower them independently. ASM #2 stated that in the building the rails were not used much for the residents to turn and reposition but as a safety net to keep them from falling. ASM #2 stated that they were practicing safety for the residents by removing the bed rails. ASM #2 stated that they thought that a grab bar could optimize safety for a resident for turning and repositioning rather than using the half side rails that were previously in place. ASM #2 stated that a grab bar would be the least restrictive and there would be less risk of entrapment. ASM #2 stated that they had some residents who were afraid that they were going to fall out of bed and they had the psychiatrist come in to evaluate them for their fears. When asked about R15, ASM #2 stated that a lot of the residents were a two person assist prior to the bed rails being removed and their level of functioning had not changed. When asked about the staffing of one CNA (certified nursing assistant) assigned on the unit for R15 for a two person assist, ASM #2 stated that the expectation was for the nurse to assist the CNA in turning and positioning the residents. On 11/16/2022 at 3:07 p.m., an interview was conducted with CNA (certified nursing assistant) #8. CNA #8 stated that R15 used the bed rail to pull up when transferring out of bed and to position and turn in bed when they had them. CNA #8 stated that R15 had voiced that they wanted the bed rails back because it was harder to get out of bed and position themselves now. CNA #8 stated that R15 told them that they only wanted the right one back. CNA #8 stated that now they had to assist R15 more physically when getting out of bed due to not having the bed rail. CNA #8 stated that R15 had bad knees and it was hard to use the low recliner chair arm to get out of bed. The facility policy Bed Rail Risk and Safety documented in part, .b. When resident choice regarding bed rails is not consistent with the facility recommendations, the resident and/or resident representative will be educated by a representative of the interdisciplinary team on the risks and resolution identified in the resident's plan of care. c. The resident's attending physician and resident representative will be informed of any variance from facility recommendation .3. Consider restricting rail use only to the times necessary (e.g., while assisting staff to reposition self) . On 11/17/2022 at approximately 12:00 p.m., ASM #4, the interim administrator and ASM #2, the director of nursing were made aware of the concern. No further information was presented prior to exit. Based on observation, resident interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate the needs and/or honor the resident's preferences for the use of bed side rails for four of 33 residents in the survey sample, Residents #38, #59, #63 and #15. The findings include: 1. For Resident #38 (R38), the facility staff failed to honor the resident's preference to have bed side rails to assist them to stand at the bedside and failed to accommodate the resident's ability to reach their bed controls. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/3/2022, Resident #38 scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring supervision for moving in the bed, transfers, walking in the room and walking in the corridor with one person assist. The resident was coded as requiring extensive assistance for their toileting needs. In Section H - Bladder and Bowel, the resident was coded as being frequently incontinent of both bowel and bladder. Observation was made of R38 on 11/15/2022 at 9:15 a.m. The resident was lying in their bed. There were no side rails on the bed. The resident's bed controller was attached to the nightstand. R38 stated they can't reach the control if they are lying on their left side as the controller is on the right side of the bed and out of their reach. When asked how long it had been this way, R38 stated they did that when they took the side rails off the bed. An interview was conducted with R38 on 11/16/2022 at 8:58 a.m. When asked if they used the side rails when they had them, R38 stated they used them for turning in the bed. They stated they need them to help him get up out of the bed. R38 stated that they used them to help him stand at the bedside to use the urinal. An interview was conducted with CNA (certified nursing assistant) #1 on 11/16/2022 at 9:00 a.m. When asked if R38 had required more assistance during ADL (activities of daily living) care since their side rails were removed, CNA #5 stated, yes, they were able to get up and stand at the bedside to urinate. [R38] now wets themselves at times. [R38] used the rails to move in bed. The Side Rail and Entrapment Risk Assessment dated, 10/31/2022 documented in part, 1. Is the resident DEPENDENT in bed mobility - no. 2. Is the resident NON-AMBULATORY or only ambulates with extensive assistance - no. 3. Does the resident have alteration in safety awareness due to cognitive decline and poor decisions making - no. 4. Will the use of side rails optimize resident independence in bed mobility and transfer - no. 5. Can the resident demonstrate use of the side rails, independently or with little prompting, for bed mobility - no. 6. Does the resident have difficulty with balance or poor trunk control when in bed or transferring t/from bed - no. 7. Does the resident have a history of postural hypotension, vertigo, syncope, or dizziness - no. 8. Is the resident on any medications that may require increased safety precautions (i.e., anticoagulants, psychoactive meds, medications with side effects of hypotension - Yes. Explain - htn (hypertension -high blood pressure). 9. Has the resident demonstrated a history of climbing over or around the rails - no. 10. Has the resident demonstrated a history of injury from use of the side rails including skin tears, bruising, etc - no. 11. Is the resident able (cognitively or functionally) to use the call bell to call for assistance - yes. 12. Has the resident or resident representative requested use of side rails - no. 13. Will the use of side rails during care provided by staff optimize resident safety and security - no . RECOMMENDATIONS: 19. Other alternative considered/trialed prior to side rails - low bed. 20. The following side rail use is recommended: no side rails indicated at this time .24. Other recommendations: Resident cannot raise or lower side rails independently. The comprehensive care plan dated 5/22/2022 failed to evidence documentation related to the use of side rails. An interview was conducted with OSM (other staff member) # 2, the director of maintenance, on 11/16/2022 at 1:04 p.m. When asked if he was involved with the removal of all the side rails, OSM #2 stated he removed the side rails the beginning of the month [November]. When asked how that come about, OSM #2 stated they had an in-service with the clinical staff, he stated he had missed it. OSM #2 stated he was told if the resident could not raise and lower the side rails, they couldn't have rails. OSM #2 stated he told them [administration] that no one could release them as the controls are on the outside of the bed rail near the frame. OSM #2 stated he was not thrilled about doing it, he felt like the facility had stepped back in time. An interview was conducted with ASM #3, the assistant director of nursing, on 11/16/2022 at 1:19 p.m. When asked the process for the use of side rails, ASM #3 stated if a resident wants or needs side rails, then an assessment is completed. ASM #3 stated, I go through that, I make sure that they are safe for them to have side rails, such as if they have an air mattress, that's one of the questions on the assessment. All rails have been removed. If there is a request by the resident, family, doctor, or therapy, we go back in and reassess the resident. When asked about the resident's ability to raise and lower the side rails, ASM #3 stated the release button is not on the bed frame, it's on the outside of the rail. ASM #3 stated she still had residents that can turn by themselves or are now a two person assist. When asked what the residents that turn are holding on to, ASM #3 stated, the bed frame, some will use the mattress. When asked about R38, ASM #3 stated when she did the assessment, they didn't use the side rails to get out of the bed. ASM #3 stated R38 is aware they are not to get up without assistance. When asked about using the urinal, ASM #3 stated the resident has been using the urinal while sitting in the bed. When asked about the placement of R38's bed control and where should they be, ASM #3 stated they should be within the resident's reach. An interview was conducted with ASM #2, the director of nursing, on 11/16/2022 at 2:35 p.m. When asked the process for a resident to have side rails, ASM #2 stated the resident must be able to raise and lower the side rails independently. When asked where that requirement is located, ASM #2 stated it's part of the CMS (The Centers for Medicare/Medicaid services) regulation. ASM #2 stated, This building had side rails not for the resident to use them but a safety net to keep the residents from falling. When asked if removing the side rails is allowing the resident reach their highest level of well-being, ASM #2 stated, We are practicing safety for the residents. The facility policy, Bed Rail Risk and Safety documented in part, Assess the Resident - 1. Any resident being considered for using a bed with bed rail(s) is evaluated by the facility's interdisciplinary team to determine whether the resident's functional status and bed mobility is improved through the use of bed rail(s), to identify any bed rail that might constitute physical restraint, and to identify individual characteristics that may increase the risk of entrapment by bed rails or mattress. 2. The bed rail evaluation, including the entrapment risk component, is completed: a. Admission, Readmission, b. Quarterly, c. At any time, there is a significant change in resident condition, i. A significant change in the resident's condition may be related to improvement and/or decline in the resident's functional, behavioral, or cognitive status as identified by the interdisciplinary team. Bed Rail Risk and Safety: 2 d. Any time the resident's bed complement is changed (e.g., addition of a specialty mattress , overlay, or an additional bed rail). 3. If the resident's evaluation identifies him or her as appropriate for the use of bed rail(s), the following procedures will be followed: a. Educate the resident/resident representative on the risks and obtain consent for use. i. The resident and/or resident representative's consent for use of the bed rails will be documented in the medical record. b. The resident's representative will be notified as appropriate c. The physician/practitioner will be notified and a specific order for the use of bed rails (identify how many / type of rails, which side or sides of the bed, and when they are to be in place) will be obtained. ASM #4, the interim administrator, and ASM #2, the director of nursing, were made aware of the above concern on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit. 2. For Resident #59 (R59), the facility staff failed to honor the resident's preference for having side rails to assist in bed mobility. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/7/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member, in moving in the bed and for transfers. Observation was made on 11/14/2022 at 6:25 p.m. of R59 in a recliner in the resident room. The bed was observed to have one side rail on the bed. An interview was conducted with R59 on 11/15/2022 at 3:21 p.m. R59 stated they wanted both rails back on the bed. R59 stated they were able to get one rails back to put their touch-controlled specialty call bell on. A second interview was conducted with R59 on 11/16/2022 at 9:16 a.m. When asked about the side rails, R59 stated when they had the other rail, on the resident's right side of the bed, they could wrap their arm over it to keep themselves over while they changed him. R59 stated they could not do that now. The Side Rail and Entrapment Risk Assessment, dated 10/31/2022, documented in part, 1. Is the resident DEPENDENT in bed mobility - no. 2. Is the resident NON-AMBULATORY or only ambulates with extensive assistance - yes. 3. Does the resident have alteration in safety awareness due to cognitive decline and poor decisions making - no. 4. Will the use of side rails optimize resident independence in bed mobility and transfer - no. 5. Can the resident demonstrate use of the side rails, independently or with little prompting, for bed mobility - no. 6. Does the resident have difficulty with balance or poor trunk control when in bed or transferring to/from bed - yes. 7. Does the resident have a history of postural hypotension, vertigo, syncope, or dizziness - no. 8. Is the resident on any medications that may require increased safety precautions (i.e., anticoagulants, psychoactive meds, medications with side effects of hypotension - Yes. Explain - psychoactive medication. 9. Has the resident demonstrated a history of climbing over or around the rails - yes. 10. Has the resident demonstrated a history of injury from use of the side rails including skin tears, bruising, etc - no. 11. Is the resident able (cognitively or functionally) to use the call bell to call for assistance - yes. 12. Has the resident or resident representative requested use of side rails - yes. 13. Will the use of side rails during care provided by staff optimize resident safety and security - no . RECOMMENDATIONS: 20. The following side rail use is recommended: no side rails indicated at this time .24. The Side Rail and Entrapment Risk Assessment, dated 11/15/2022 (during survey), documented in part, 1. Is the resident DEPENDENT in bed mobility - yes. 2. Is the resident NON-AMBULATORY or only ambulates with extensive assistance - yes. 3. Does the resident have alteration in safety awareness due to cognitive decline and poor decisions making - no. 4. Will the use of side rails optimize resident independence in bed mobility and transfer - no. 5. Can the resident demonstrate use of the side rails, independently or with little prompting, for bed mobility - no. 6. Does the resident have difficulty with balance or poor trunk control when in bed or transferring to/from bed - no. 7. Does the resident have a history of postural hypotension, vertigo, syncope, or dizziness - no. 8. Is the resident on any medications that may require increased safety precautions (i.e., anticoagulants, psychoactive meds, medications with side effects of hypotension - Yes. Explain - htn. 9. Has the resident demonstrated a history of climbing over or around the rails - no. 10. Has the resident demonstrated a history of injury from use of the side rails including skin tears, bruising, etc - no. 11. Is the resident able (cognitively or functionally) to use the call bell to call for assistance - yes. 12. Has the resident or resident representative requested use of side rails - yes. 13. Will the use of side rails during care provided by staff optimize resident safety and security - no . RECOMMENDATIONS: 19. Other alternatives considered/trialed prior to side rails. Low bed. Positioners. 20. The following side rail use is recommended: 22. If only 1 grab bar, 1/4, 1/2 or full side rails is used, identify side - left. 23. Reason for side rail use: to station soft touch call bell. The comprehensive care plan dated 5/11/2022 documented in part, Focus: [R59] has an ADL (activity of daily living) self-care performance deficit AEB (as exhibited by) requires assist with ADLs. The Interventions documented in part, May use left upper side rail to assist with call bell placement. Revised on 11/15/2022. An interview was conducted with LPN (licensed practical nurse) #4 on 11/16/2022 at 9:31 a.m. When asked if R59 had side rails before, LPN #4 stated, yes. When asked why they were removed, LPN #4 stated the same reason for everyone else, the resident couldn't raise or lower the side rails independently. LPN #4 stated [R59] got one back. When asked why, LPN #4 stated she was not sure but she believed it was to put his call bell on. An interview was conducted with OSM (other staff member) # 2, the director of maintenance, on 11/16/2022 at 1:04 p.m. When asked if he was involved with the removal of all the side rails, OSM #2 stated he removed the side rails the beginning of the month (November). When asked how that come about, OSM #2 stated they had an in-service with the clinical staff, he stated he had missed it. OSM #2 stated he was told if the resident could not raise and lower the side rails, they couldn't have rails. OSM #2 stated he told them (administration) that no one could release them as the controls are on the outside of the bed rail near the frame. OSM #2 stated he was not thrilled about doing it, he felt like the facility had stepped back in time. An interview was conducted with ASM #3, the assistant director of nursing, on 11/16/2022 at 1:19 p.m. When asked the process for the use of side rails, ASM #3 stated if a resident wants or needs side rails, then an assessment is completed. ASM #3 stated, I go through that, I make sure that they are safe for them to have side rails, such as if they have an air mattress, that's one of the questions on the assessment. All rails have been removed. If there is a request by the resident, family, doctor, or therapy, we go back in and reassess the resident. When asked about the resident's ability to raise and lower the side rails, ASM #3 stated the release button is not on the bed frame, it's on the outside of the rail. ASM #3 stated she still had residents that can turn by themselves or are now a two person assist. When asked what the residents that turn are holding on to, ASM #3 stated, the bed frame, some will use the mattress. When asked about R59, ASM #3 stated, We've now made him more dependent. When asked if that is promoting his highest level of well -being and honoring his preference, ASM #3 stated, If he feels that way, then no, we are not promoting his highest level of well-being. An interview was conducted with ASM #2, the director of nursing, on 11/16/2022 at 2:35 p.m. When asked the process for a resident to have side rails, ASM #2 stated the resident must be able to raise and lower the side rails independently. When asked where that requirement is located, ASM #2 stated it's part of the CMS (centers for Medicare/Medicaid services) regulation. ASM #2 stated, This building had side rails not for the resident to use them but a safety net to keep the residents from falling. When asked if removing the side rails is allowing the resident reach their highest level of well-being, ASM #2 stated, We are practicing safety for the residents. ASM #4, the interim administrator, and ASM #2, the director of nursing, were made aware of the above concern on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit. 3. For Resident #63 (R63) the facility staff failed to honor the resident's preference for the use of side rails to assist in bed mobility and reduce anxiety. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 10/5/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section G - Functional Status R63 was coded as requiring extensive assistance of one staff member for bed mobility and extensive assistance of two staff members for transfers. R63 was observed on 11/15/2022 at approximately 8:30 a.m., in bed. There were no side rails attached to the bed. R63 stated they want their side rails back. R63 stated, They took them off because of some law. R63 stated they want to be able to hold onto [rails] when they turn, and they can try to reposition themselves in bed. The Side Rail and Entrapment Risk Assessment, dated 11/1/2022, documented in part, 1. Is the resident DEPENDENT in bed mobility - yes. 2. Is the resident NON-AMBULATORY or only ambulates with extensive assistance - yes. 3. Does the resident have alteration in safety awareness due to cognitive decline and poor decisions making - no. 4. Will the use of side rails optimize resident independence in bed mobility and transfer - no. 5. Can the resident demonstrate use of the side rails, independently or with little prompting, for bed mobility - no. 6.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to maintain grievance logs from 7/20/2022 through 11/15/2022 potentially affecting most of the 33 residents in the survey sample. The findings include: Upon entrance to the facility on [DATE] at approximately 7:00 p.m. a request was made for the grievance logs. A second request was made on 11/15/2022 at approximately 9:00 a.m. On 11/15/2022 the survey team received a document titled, Concern Log. The document dated concerns from 1/13/2022 through 7/20/2022. On 11/15/2022 at 1:06 p.m., an interview was conducted by another surveyor with OSM (other staff member) #4, long term care ombudsman. OSM #4 stated that they had received multiple calls from residents and family members regarding the bed rails being removed from residents beds. OSM #4 stated that they had been told that maintenance had removed all of the bed rails about two or three weeks ago. OSM #4 stated that they were told that there were new regulations and the facility had to be restraint free so they had removed all of the bed rails and go through the steps to see if the residents needed the bed rails. OSM #4 stated that they had met with the residents and the administrative staff about this concern but had no resolution at the current time. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 11/15/2022 at 3:47 p.m. When asked where the grievance logs since July 2022 were, ASM #2 stated, We haven't kept track of them. When asked why, ASM #2 did not respond. When asked who is responsible for the tracking of grievances, ASM #2 stated, Social services. An interview was conducted with OSM (other staff member) #1, the director of admissions, on 11/16/2022 at approximately 12:15 p.m. When asked the process for a resident and/or family member to file a grievance, OSM #1 stated, the process had been if we have any complaints or concerns, we bring them to the administrator in the morning meeting, he would address it with whichever department is involved. He would do the follow up on that. When asked if a log of grievances is kept, OSM #1 stated she did not know. When asked when the previous administrator left, OSM #1 stated she believed it was about a month ago. An interview was conducted with ASM #4, the interim administrator, on 11/16/2022 at 1:00 p.m. When asked the process for grievances, ASM #4, stated the process was the administrator was previously handling them. We are moving to having the social worker take over the log and grievance book. It was verified with ASM #4 the facility had no documentation of a log since the end of July. When asked how long the administrator had been gone, ASM #4 stated, within the last 30 days. The facility policy, Resident Grievance Procedure documented in part, It is the policy of [name of corporation] to recognize that all residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal .Procedure: 2. The facility will designate a staff member as the Grievance Official who is responsible for: a. Overseeing the grievance process. b. Receiving and tracking grievances through to their conclusion. C. Leading any necessary investigation by the facility. d. Maintaining the confidentiality of all information associated with grievances, for example the identity of the resident for those grievances submitted anonymously. e. Issuing written grievances decisions to the resident and or resident representative upon request . e. The facility will maintain a Grievance record for 3 years of written grievance decisions to include: 1. the date the grievance was received. 2. A summary statement of the resident/resident representative's grievance. 3. Steps taken to investigate the grievance . 4. A summary of the pertinent findings or conclusion regarding the expressed concern. 5. A statement as the whether the grievance was confirmed of not confirmed. 6. Any corrective action taken or to be taken by the facility as a result of the grievance. 7. The date of the written decision. ASM #1, the interim administrator, and ASM #2, were made aware of the above concern on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit.

4. For Resident #54 (R54), the facility staff failed to develop the comprehensive care plan to include the use of antipsychotic medications. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/13/2022, the resident was assessed as being severely impaired for making daily decisions. Section N documented R54 receiving antipsychotics during the assessment period. The physician's order summary report dated 11/16/2022 documented in part, Risperdal Tablet 0.25 MG (milligram) (risperidone) Give 1 tablet by mouth three times a day related to: Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition. Order Date: 09/15/2022. Start Date: 09/15/2022. On 11/16/2022 at 3:27 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that care plans were created on admission based on the nursing assessment and then the MDS (minimum data set) team would use that to build on. LPN #5 stated that the purpose of the care plan was to have a plan of care for nursing and all staff to see the goals and interventions in place for the resident. LPN #5 stated that they would expect antipsychotics and associated behaviors to be on the care plan. On 11/16/2022 at 1:36 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing. ASM #3 stated that when they switched over to the new electronic medical record the former director of nursing and a group from the new facility owner came and reviewed all of the care plans at that time. ASM #3 stated that the former director of nursing worked with them, updated them and entered the new care plans into the current electronic medical record. ASM #3 stated that once they were up and running with the new system they started tweaking the care plans and adding to them. ASM #3 stated that residents on antipsychotic medication should have a care plan to address that. On 11/16/2022 at 4:02 p.m., an interview was conducted with RN (registered nurse) #3, MDS coordinator. RN #3 stated that prior to switching out the electronic medical records all of the care plans were printed out and put on the nursing units so the staff had access to them. RN #3 stated that the traditional baseline care plans were put into the new electronic medical record and they have worked to get them up to date as the MDS assessments have been completed. On 11/16/2022 at 6:17 p.m., ASM #4, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was presented prior to exit. Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 33 residents in the survey sample, Residents #53, #51, #63 and #54. The findings include: 1. For Resident #53, the facility staff failed to develop a care plan for the use of oxygen. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with the assessment reference date of 10/15/2022, the resident coded as having no short or long term memory issues. In Section O - Special Treatment, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility. Review of the comprehensive care plan, last updated 11/14/2022, failed to evidence documentation of the use of oxygen for R53. R53 was observed on 11/15/2022 at approximately 8:45 a.m. with oxygen on via a nasal cannula. The oxygen concentrator was set at 2 LPM (liters per minute). A second observation was made on 11/15/2022 at 11:53 a.m. R53 was in the wheelchair with the oxygen on at 2 LPM via a nasal cannula with a portable tank secured to the wheelchair. Review of the physician orders failed to evidence a physician order for the use of oxygen. An interview was conducted with LPN (licensed practical nurse) #4 on 11/16/2022 at 10:20 a.m. LPN #4 was asked to review R53's physician orders. When asked if she saw an order for the use of oxygen, LPN #4 stated, no and there needed to be a physician order for the use of oxygen. When asked if the resident is on oxygen, should that be addressed in the care plan, LPN #4 stated, yes. The facility policy, Care Planning - Comprehensive Person-Centered, documented in part, POLICY: 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. ASM (administrative staff member) #4, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit. 2. For Resident #51 (R51), the facility staff failed to develop a comprehensive care plan to address the use of an anticoagulant On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/23/2022, the resident was coded as having no short or long term memory difficulties. In Section N - Medications, the resident was coded as receiving an anticoagulant medication during seven days of the look back period. The physician order dated, 8/27/2022 documented, Eliquis (used to prevent blood clots) (1) 5 mg (milligrams) 1 tablet twice daily. Review of the comprehensive care plan dated, 5/11/2022, failed to evidence documentation for the use of an anticoagulant medication. An interview was conducted with RN (registered nurse) #6, the MDS nurse, on 11/17/2022 at 8:46 a.m. When asked if a resident is on an anticoagulant, should that be addressed on the care plan, RN#6 stated, yes. RN #6 confirmed the anticoagulant use wasn't on the care plan. ASM (administrative staff member) #4, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on 11/17/2022 at 12:06 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a613032.html 3. For Resident #63, the facility staff failed to develop a care plan for the use of insulin and psychotropic medications. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 10/5/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section N - Medications, R63 was coded as receiving seven days of insulin injections and seven days of an anti-psychotic, antidepressant and anti-anxiety medications. The physician orders dated 9/29/2022, documented, Aripiprazole (an antipsychotic medication) (1) Tablet; give 20 mg (milligrams) by mouth one time a day related to BIPOLAR DISORDER. The physician order dated, 11/11/2022, Clonazepam Tablet (used to treat seizures and panic attacks) (2) disintegrating 0.25 mg; give 1 tablet my mouth every day shift every Mon, Wed, Fri, related to generalized anxiety disorder; give 1 hour before leaving for hemodialysis. The physician order dated, 9/28/2022, documented, Insulin Glargine Solution (long acting insulin to treat diabetes) (3) 100 units/ML (milliliters); inject 20 unit subcutaneously one tine a day for diabetes. The physician order dated, 9/29/2022, documented, Sertraline HCL (hydrochloride) (used to treat depression, obsessive compulsive disorder and panic attacks) (4) tablet 50 mg; give 1 tablet by mouth in the evening related to BIPOLAR DISORDER. The physician order dated, 11/1/2022, documented, Novolog Flex Pen Solution (used to treat diabetes) (5) Pen-Injector 100 Unit/ML; inject as per sliding scale before meals and at bedtime. Review of the comprehensive care plan dated, 11/10/2022, failed to evidence the resident's use of psychotropic medications and the use of insulin to treat diabetes. An interview was conducted with LPN (licensed practical nurse) #4, the unit manager on 11/16/2022 at 10:10 a.m. LPN #4 stated the care plan is the outline of how to care for a resident, their preferences, and what the resident needs. When asked who's responsible for developing the care plans, LPN #4 stated it's normally the unit mangers, assistant director of nursing, director of nursing, therapy, and any department head. An interview was conducted with RN (registered nurse) #3, the MDS nurse, on 11/16/2022 at 3:58 p.m. When asked if a resident is a diabetic and is receiving insulin, should that be addressed on the care plan, RN #3 stated, it normally is. When asked if a resident is on psychotropic medications, should that be addressed on the care plan, RN #3 stated, yes. After reviewing the care plan, RN #3 stated that neither the insulin nor psychotropic medications were documented on the care plan. ASM (administrative staff member) #4, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on 11/17/2022 at 12:06 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603012.html (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682279.html (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600027.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a605013.html

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to facilitate communication with the dialysis center for one of 33 residents in the survey sample, Resident #63 (R63). The findings include: For Resident #63, the facility staff failed to have a communication system in place to facilitate communication between the facility and the dialysis center. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 10/5/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, R63 was coded as receiving dialysis while a resident at the facility. An interview was conducted with R63 on 11/15/2022 at approximately 8:45 a.m. When asked if they took any papers or a notebook to give to the dialysis staff when they go to dialysis, R63 stated, no. R63 stated they go to dialysis on Monday, Wednesday, and Friday. Review of the clinical record revealed one form titled, Dialysis Assessment dated 11/4/2022. The form was filled in by both the facility and the dialysis center. A request was made on 11/15/2022 for additional Dialysis Assessment forms. The comprehensive care plan dated, 9/29/2022, documented in part, Focus: The resident has ESRD (end stage renal disease) and received hemodialysis at [name of dialysis center] in [name of town] M, W, F (Monday, Wednesday, Friday). The Interventions documented, If bleeding from the vascular access is not controlled, apply direct pressure, call the dialysis team/nephrologist to determine the need for the resident to be transported emergently to the ED (emergency department). Pre-Post dialysis weights. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis M, W, F. Auscultation/palpation of the AV (arterial Venous) fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. Do not draw blood or take B/P (blood pressure) in arm with graft. An interview was conducted with LPN (licensed practical nurse) #6 on 11/16/2022 at 7:39 a.m. When asked where the dialysis communication book for R63 was, LPN #6 stated she did not believe they had one. When asked what paperwork goes with the resident to dialysis, LPN #6 stated, the face sheet, medication list, and the dialysis assessment form. When asked where these forms are stored when the resident gets back from dialysis, LPN #6 stated she puts them in the chart, but she comes back after she is off. An interview was conducted with LPN #4, the unit manager, on 11/16/2022 at 9:21 a.m. When asked what documents are sent with the residents who go to dialysis, LPN #4 stated, the dialysis assessment form, current list of medications and lunch. When asked where the dialysis assessment sheet is filed upon the resident's return from dialysis, LPN #4 stated, it's given to medical record to scan in. LPN #4 stated most of the time they (dialysis center) don't send it back. We send them but they won't send it back. LPN #4 stated she does not call the dialysis center for the forms, [the resident] gets back around 4:30 p.m. to 5:00 p.m. LPN #4 stated maybe if we sent a binder, that might work better. When asked what the purpose of the assessment form was, LPN #4 stated it's to put the vitals, medication changes or observations on. We are trying to communicate with them what's going on with her and it's them telling us what they did; was her BP normal during the process. LPN #4 was asked, if you don't get the form back is that communicating with them, LPN #4 stated, no. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 11/16/2022 at 2:57 p.m. who stated there is a communication form we send with the resident. When asked what the purpose of the form was, ASM #2 stated it's so we can monitor their care. They [dialysis center] usually don't fill out their form and send it back here, and the staff should be calling. There has to be continuity of care between the dialysis center and us. The facility policy, End Stage Renal Disease - Care of Resident, documented in part, 3. Agreement between the facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to: .b. communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination and collaboration. ASM #4, the interim administrator, and ASM #2 were made aware of the above concern on 11/16/2022 at 6:15 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for three of five CNA's (certified nursing assistants) reviewed CNA #2, #3, and #5. The findings include: During the Sufficient and Competent Staffing facility task review on 11/15/22 at 3:00 PM there was no evidence of performance evaluations for three of five CNA's (certified nursing assistants) reviewed. On 11/15/22 at 9:00 AM, ASM (administrative staff member) #1, the regional director of operations was provided with the list of five CNA's with a request for evidence of performance review. On 11/15/22 at 12:30 PM, ASM #1, the regional director of operations, provided the employee files requested. Upon review, the following was revealed: 1. CNA #2 with a date of hire of 11/17/20 had an initial orientation evaluation in 3/2021. There was no performance evaluation in the last 12 months. 2. CNA #3 with a date of hire of 3/16/92 evidenced the last evaluation in 3/2020. There was no performance evaluation in the last 12 months. 3. CNA #5 with a date of hire of 8/18/97, evidenced the last evaluation in 7/2020. There was no performance evaluation in the last 12 months. On 11/15/22 at 3:00 PM, OSM #5, the human resources manager stated, We do not have any more performance reviews. I have been auditing the files, there are many missing items and I have been working on getting the files correct. On 11/15/22 at 5:45 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's policy Performance Evaluations policy with no date, revealed, The job performance of each employee shall be reviewed and evaluated at least annually. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review it was determined that the facility staff failed to ensure one of 33 residents in the survey sample was free of unnecessary medications, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to hold the Hydrochlorothiazide (1) as ordered when the resident's systolic blood pressure (2) was less than 140 ten times during October 2022 and five times during November 2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident was cognitively intact for making daily decisions. R16 was coded as receiving a diuretic during the look back period and having high blood pressure. The physician orders for R16 documented in part, Hydrochlorothiazide 12.5 MG (milligram) * Give 1 tablet orally every day shift related to Essential (Primary) Hypertension. HOLD IF SBP (systolic blood pressure) < (less than) 140. Order Date: 06/13/2022. Start Date: 06/14/2022. A review of R16's MAR (medication administration record) for October 2022 revealed the following blood pressures: 10/12/2022 Morning 137/82; 10/19/2022 Morning 134/70; 10/21/2022 Morning 132/71; 10/22/2022 Morning 121/68; 10/23/2022 Morning 121/68; 10/24/2022 Morning 122/66; 10/25/2022 Morning 128/72; 10/26/2022 Morning 119/73; 10/27/2022 Morning 122/75; and 10/28/2022 Morning 126/73. Further review of the October 2022 MAR revealed that Hydrochlorothiazide 12.5 mg was administered to R16 on each of the dates listed above when the systolic blood pressure was less than 140. A review of R16's MAR (medication administration record) for November 2022 revealed the following blood pressures: 11/1/2022 Morning 126/71; 11/6/2022 Morning 137/72; 11/8/2022 Morning 138/74; 11/10/2022 Morning 125/59; and 11/12/2022 Morning 135/64. Further review of the November 2022 MAR revealed that Hydrochlorothiazide 12.5 mg was administered to R16 on each of the dates listed above when the systolic blood pressure was less than 140. On 11/16/2022 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that during medication administration the medication was checked against the order twice and documented after administration. LPN #4 stated that there were some medications that required vital signs to be checked prior to administration and had parameters in the orders to follow for administration. LPN #4 reviewed the order for Hydrochlorothiazide for R16 and stated that according to the order that the medication should be held if the systolic blood pressure was less than 140. LPN #4 reviewed the MAR for R16 dated October 2022 and November 2022 and stated that the medication had been administered on the dates above and should have been held because the systolic blood pressure was below 140. The facility policy General Guidelines for Medication Administration revised 8/2020 documented in part, Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to administer .Medications are administered in accordance with written orders of the prescriber . On 11/17/2022 at 12:00 p.m., ASM (administrative staff member) #4, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. (1) Hydrochlorothiazide is used alone or in combination with other medications to treat high blood pressure. Hydrochlorothiazide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease and to treat edema caused by using certain medications including estrogen and corticosteroids. Hydrochlorothiazide is in a class of medications called diuretics ('water pills'). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. This information is taken from the website: https://medlineplus.gov/druginfo/meds/a682571.html (2) Systolic pressure is the pressure when the ventricles pump blood out of the heart. Diastolic pressure is the pressure between heartbeats when the heart is filling with blood .For most adults, a normal blood pressure is less than 120 over 80 millimeters of mercury (mm Hg), which is written as your systolic pressure reading over your diastolic pressure reading - 120/80 mm Hg. Your blood pressure is considered high when you have consistent systolic readings of 130 mm Hg or higher or diastolic readings of 80 mm Hg or higher. This information is taken from the website: https://www.nhlbi.nih.gov/health/high-blood-pressure#:~:text=Systolic%20pressure%20is%20the%20pressure,day%20based%20on%20your%20activities.

Based on staff interview, facility document review, and clinical record review it was determined that the facility staff failed to administer medications in a manner free of significant errors for one of 33 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to hold the Hydrochlorothiazide (1) as ordered when the resident's systolic blood pressure (2) was less than 140 ten times during October 2022 and five times during November 2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident was cognitively intact for making daily decisions. R16 was coded as receiving a diuretic during the look back period and having high blood pressure. The physician orders for R16 documented in part, Hydrochlorothiazide 12.5 MG (milligram) * Give 1 tablet orally every day shift related to Essential (Primary) Hypertension. HOLD IF SBP (systolic blood pressure) < (less than) 140. Order Date: 06/13/2022. Start Date: 06/14/2022. A review of R16's MAR (medication administration record) for October 2022 revealed the following blood pressures: 10/12/2022 Morning 137/82; 10/19/2022 Morning 134/70; 10/21/2022 Morning 132/71; 10/22/2022 Morning 121/68; 10/23/2022 Morning 121/68; 10/24/2022 Morning 122/66; 10/25/2022 Morning 128/72; 10/26/2022 Morning 119/73; 10/27/2022 Morning 122/75; and 10/28/2022 Morning 126/73. Further review of the October 2022 MAR revealed that Hydrochlorothiazide 12.5 mg was administered R16 on each of the dates listed above when the systolic blood pressure was less than 140. A review of R16's MAR (medication administration record) for November 2022 revealed the following blood pressures: 11/1/2022 Morning 126/71; 11/6/2022 Morning 137/72; 11/8/2022 Morning 138/74; 11/10/2022 Morning 125/59; and 11/12/2022 Morning 135/64. Further review of the November 2022 MAR revealed that Hydrochlorothiazide 12.5 mg was administered R16 on each of the dates listed above when the systolic blood pressure was less than 140. On 11/16/2022 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that during medication administration the medication was checked against the order twice and documented after administration. LPN #4 stated that there were some medications that required vital signs to be checked prior to administration and had parameters in the orders to follow for administration. LPN #4 reviewed the order for Hydrochlorothiazide for R16 and stated that according to the order that the medication should be held if the systolic blood pressure was less than 140. LPN #4 reviewed the MAR for R16 dated October 2022 and November 2022 and stated that the medication had been administered on the dates above and should have been held because the systolic blood pressure was below 140. The facility policy General Guidelines for Medication Administration revised 8/2020 documented in part, Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to administer .Medications are administered in accordance with written orders of the prescriber . On 11/17/2022 at 12:00 p.m., ASM (administrative staff member) #4, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. (1) Hydrochlorothiazide is used alone or in combination with other medications to treat high blood pressure. Hydrochlorothiazide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease and to treat edema caused by using certain medications including estrogen and corticosteroids. Hydrochlorothiazide is in a class of medications called diuretics ('water pills'). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. This information is taken from the website: https://medlineplus.gov/druginfo/meds/a682571.html (2) Systolic pressure is the pressure when the ventricles pump blood out of the heart. Diastolic pressure is the pressure between heartbeats when the heart is filling with blood .For most adults, a normal blood pressure is less than 120 over 80 millimeters of mercury (mm Hg), which is written as your systolic pressure reading over your diastolic pressure reading - 120/80 mm Hg. Your blood pressure is considered high when you have consistent systolic readings of 130 mm Hg or higher or diastolic readings of 80 mm Hg or higher. This information is taken from the website: https://www.nhlbi.nih.gov/health/high-blood-pressure#:~:text=Systolic%20pressure%20is%20the%20pressure,day%20based%20on%20your%20activities.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to properly store food products in the walk in refrigerator, discard expired food, and maintain the dishwasher in good repair in one of two kitchens in the facility. The findings include: On 11/14/2022 at 6:37 p.m., an observation of the kitchen on the Grace unit was conducted with OSM (other staff member) #8, dietary cook. Observation of the walk in refrigerator revealed a 12 pound container of homestyle potato salad with a use by date of 10/25/2022 on the lid. The container was observed to be unopened. OSM #8 observed the container and stated that the potato salad was old and needed to be thrown away. OSM #8 stated that the container was available for use. Observation of the walk in freezer revealed a 10 pound box of diced grilled chicken breast sitting on the freezer floor, a 16.72 pound box of oven ready four cheese pizzas sitting on the freezer floor and a 10 pound box of hotdogs sitting on the freezer floor. OSM #8 stated that they did not have a lot of room in the freezer, however the boxes should not be stored on the floor. Observation of the dishwasher on the Grace unit revealed a plaque on the outside of the dishwasher documenting a minimum water temperature of 120. Observation of three dishwasher cycles revealed the highest temperature observed on the dishwasher temperature gauge to be 116 during the cycles. OSM #8 was asked to confirm the temperature during the dishwashing cycle and stated that they could not see the gauge very well because it was low to the ground and very small. OSM #8 stated that the gauge did not appear to be getting to the temperature and they would report this to the supervisor. OSM #8 stated that the dishwasher had recently been repaired and they frequently had issues with it. On 11/15/2022 at 8:42 a.m., an observation of the Grace unit dishwasher was made with OSM #2, the director of maintenance and OSM #7, the assistant dietary manager. OSM #2 stated that the dishwasher was leased from the vendor and they had multiple problems with getting service from them. OSM #7 proceeded to run the dishwasher and observed the temperature gauge staying below 120 during the cycle. OSM #2 stated that the dietary staff had a thermometer that could be used to check the temperature during the wash if the gauge was not showing the required temperature. OSM #2 and OSM #7 were made aware of the observations on 11/14/2022 and OSM #7 stated that they would educate their staff on reading the gauge and using the thermometer to confirm the water temperature. OSM #2 provided a thermometer and checked the water temperature during the dishwasher cycle which showed 122.4 on the thermometer and 115 on the dishwasher temperature gauge. OSM #2 stated that it appeared that the temperature gauge was not accurate on machine and they needed to call the vendor to come in. A request was made to OSM #2 and OSM #7 for the manufacturers instructions for use and the past three months of temperature logs for the dishwasher. Review of the temperature logs dated 9/1/2022-11/15/2022 provided by OSM #2 documented the dishwasher temperature at 120 degrees or above daily for breakfast, lunch and dinner. On 11/15/2022 at approximately 1:30 p.m., OSM #2 provided instructions for use for the dishwasher which documented in part, .Water supply temp 140 [degrees] F (Fahrenheit) Recommended (120 [degrees] F Minimum Water Temperature) . The facility policy Dishwashing Machine Use documented in part, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation .7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately . On 11/16/2022 at 6:17 p.m., ASM (administrative staff member) #4, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for five of five CNA (certified nursing assistant) record reviews. The findings include: The facility staff failed to provide the evidence of required certification for five of five CNAs that were employed for greater than on year, CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5. During the Sufficient and Competent Staffing facility task review on [DATE] at 3:00 PM revealed that the following CNA certifications were verified after expiration from the Virginia Department of Health Professions (DHP) as follows: 1. CNA #1 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from the DHP until [DATE]. 2. CNA #2 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from the DHP until [DATE]. 3. CNA #3 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from DHP until [DATE]. 4. CNA #4 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from DHP until [DATE]. 5. CNA #5 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from DHP until [DATE]. On [DATE] at 3:00 PM, OSM #5, the human resources manager stated, we do not have any more performance reviews. I have been auditing the files, there are many missing items and I have been working on getting the files correct. I know the certification has to be pulled from the Virginia Department of Health Professions site prior to the end of the month of expiration. On [DATE] at 5:45 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's policy Licensure, Certification and Registration of Personnel policy with no date, revealed, A copy of the current license, certification or registration must be filed in the employee's personnel record. A copy of the recertification must be filed prior to the expiration of current licensure, certification or registration. No further information was provided prior to exit.

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to provide abuse and dementia management training for five of six agency employee reviews. The findings include: The facility staff failed to provide abuse and dementia management training to RN (registered nurse) #5, LPN (licensed practical nurse) #3, CNA (certified nursing assistant) #12, CNA #13 and LPN #9. A complaint submitted to the state agency on 6/29/22 alleged a concern regarding agency staff training. RN #5 was hired on 9/2/22. LPN #3 was hired on 8/21/22. CNA #12 was hired on 2/12/22. CNA #13 was hired on 6/9/22. LPN #9 was hired on 3/31/22. A review of employee records failed to reveal evidence of abuse and dementia management training for the above staff. On 11/16/2022 at 5:37 p.m., an interview was conducted with ASM (administrative staff member) #4, the interim administrator. ASM #4 stated contracted staff go through training prior to working at the facility. ASM #4 stated contracted staff are provided an orientation packet which includes electronic medical record training and abuse, neglect and misappropriation training. ASM #4 stated staff members complete the packet and a copy of the signed documents are kept by the facility. On 11/17/2022 at 10:01 a.m., an interview was conducted with OSM (other staff member) #5, the human resource manager. OSM #5 stated contracted agency staff members are trained and screened prior to working in the facility. OSM #5 stated she has been working at the facility since May of this year and has been working to catch up files for contracted agency staff members who work at the facility. OSM #5 stated that prior to an agency staff member coming to the facility for their first shift, she receives information from the agency regarding their background check, COVID vaccination card, license check and PPD status (tuberculosis test). OSM #5 stated contracted agency staff members receive an orientation packet which contains facility policies and abuse, neglect and misappropriation training. The facility policy titled, Abuse documented in part, .At a minimum, education on abuse, neglect, and exploitation will be provided to facility staff upon hire and annually. In addition to the freedom from abuse, neglect, mistreatment of residents, misappropriation of property and exploitation requirements in 483.12, the organization will also provide training to their staff on: .Dementia management and resident abuse prevention . On 11/17/22 at 12:55 p.m., ASM #4 and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. Complaint deficiency.

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to continuously employ a registered dietitian (RD) or qualified nutritional professional. The findings include: The facility staff failed to employ a registered dietitian or qualified nutritional professional from 4/30/22 until 6/15/22. A complaint submitted to the state agency on 6/29/22 alleged there was no registered dietitian employed by the facility since 5/1/22. A review of facility documents/timesheets revealed a RD began employment on 6/15/22. On 11/16/22 at 5:52 p.m., an interview was conducted with ASM (administrative staff member) #4, the interim administrator. ASM #4 stated the former RD left the facility right before the facility was sold to another company. ASM #4 stated another RD was not employed until 6/15/22. On 11/17/22 at 12:35 p.m., ASM #4 stated the former RD's last day of employment was 4/30/22 (no RD or qualified nutritional profession was employed at the facility from 4/30/22 until 6/15/22). On 11/17/22 at 12:55 p.m., ASM #4 and ASM #2, the director of nursing, were made aware of the above concern. The facility policy titled, Dietician (Dietitian) documented, POLICY: A qualified, competent, and skilled Dietitian will help oversee the food and nutrition services in the facility. DEFINITIONS: Qualified Dietitian Or Other Clinically Qualified Nutrition Professional is one who: Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed . No further information was presented prior to exit. Complaint deficiency.

Based on staff interview and facility document review, the facility staff failed to implement a QAPI (Quality Assurance and Performance Improvement) program potentially affecting all residents in the survey sample. The findings include: The facility staff failed to provide evidence of a QAPI program prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI program/documentation prior to August 2022. ASM #2 stated the QAPI program is supposed to consist of identifying issues through concerns from department heads and their staff, the concerns should be taken to the QAPI meetings, the QAPI team should develop action plans, staff should be educated, processes should be implemented, the plan should be evaluated, and if the plan is not working then new interventions should be started. On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Quality Assurance Performance Improvement (QAPI) Committee documented, The facility will maintain systems and processes to ensure that the quality assurance/performance improvement program identifies and addresses issues and/or risks and that implements corrective action plans as necessary . No further information was presented prior to exit.

Based on staff interview and facility document review, the facility staff failed to implement policies and procedures for QAPI (Quality Assurance and Performance Improvement) program feedback, data systems and monitoring potentially affecting all residents in the survey sample. The findings include: The facility staff failed to implement policies and procedures for a systematic approach to determine underlying causes of problems impacting larger systems, corrective action and monitoring of the effectiveness of performance improvement activities prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI program/documentation prior to August 2022. ASM #2 stated the QAPI program is supposed to consist of identifying issues through concerns from department heads and their staff, the concerns should be taken to the QAPI meetings, the QAPI team should develop action plans, staff should be educated, processes should be implemented, the plan should be evaluated, and if the plan is not working then new interventions should be started. In regards to determining underlying causes of problems impacting larger systems, corrective action and monitoring of the effectiveness of performance improvement activities, ASM #2 stated the QAPI team completes a root cause analysis, implements the action plan, includes floor staff when working the action plan then follows up and verifies the results. On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program- Governance and Leadership documented, 4. The responsibilities of the QAPI committee are to: a. Collect and analyze performance indicator data and other information. b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services; c. Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process; d. Utilize root cause analysis to help identify where identified problems point to underlying systemic problems; e. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; f. Establish benchmarks and goals by which to measure performance improvement; g. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals . No further information was presented prior to exit.

Based on staff interview and facility document review, the facility staff failed to conduct required QAPI (Quality Assurance and Performance Improvement) meetings potentially affecting all residents in the survey sample. The findings include The facility staff failed to evidence quarterly QAPI meetings were conducted prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI meetings prior to August 2022. ASM #2 stated the QAPI committee should meet quarterly and consists of the social worker, director of nursing, administrator, dietary manager, activities director, laundry manager, a CNA (certified nursing assistant) and the medical director. On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Quality Assurance Performance Improvement (QAPI) Committee documented, 4. The facility will maintain a QAPI committee consisting at a minimum of: a. The director of nursing service; b. The medical director or his or her designee; c. The facility Infection Preventionist; d. At least three other members of the facility's staff, at least one of whom must be the administrator, owner, a board member or other individual in a leadership role .6. The committee will meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program . No further information was presented prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to implement an ongoing infection prevention and control program (IPCP) potentially affecting all residents in the survey sample. The findings include: There were no infection control tracking logs available for review. Upon entrance on 11/14/2022 a request was made for the infection control tracking logs. A second request was made on 11/16/2022. ASM (administrative staff member) #2, the director of nursing, stated on 11/16/2022 at 5:25 p.m. the facility has no infection control tracking logs before August 2022. They presented a notebook with the floor plans of the facility. It had colored lines on rooms with infections. On 11/17/2022 at 10:08 a.m. an interview was conducted with ASM #2, and ASM #3, the assistant director of nursing. When asked if they had a line listing of the infections in the facility with type of infections, source, culture results and/or x-ray results, ASM #2 stated, no. When asked the process for tracking and trending infections in the facility, ASM #2 stated they know what antibiotic, what organism is being treated, watch if there is a pattern on a particular room, assignment, or shift. When asked where all of this is located, ASM #2 stated she hadn't seen any tracking and trending of infections since she arrived the end of July. When asked if she had seen any tracking and trending logs, ASM #3 stated, in the 45 days she was the acting director of nursing, she did not see any logs. The facility policy, Surveillance for \Infections documented in part, Policy: The infection preventionist [designee] will conduct ongoing surveillance for healthcare-associated infections [HAIs] and other epidemiologically significant infections that have substantial impact on potential resident outs comes and that may require transmission -based precautions and other preventative interventions .Gathering Surveillance Data: 1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data .Data Collection and Recording: 1. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate. 2. Identifying information (i.e., resident's name, age, room number, unit and attending physician); a. Diagnosis. b. admission date, date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test). c. Infection site (be as specific as possible, e.g., cutaneous infections should be listed as pressure ulcer, left foot, pneumonia as right upper lobe, etc.) d. Pathogens. e. Invasive procedures or risk factors (i.e., surgery, indwelling tubes, Foley, fractured hip, malnutrition, altered mental status). f. Pertinent remarks (additional relevant information; (temperature, other symptoms of specific infection, white blood cell count, etc.) Also, record if the resident is admitted to the hospital or expires). g. Treatment measures and precautions (interventions and steps taken that may reduce risk). h. Using the current suggested criteria for healthcare-associated infections, determine if the resident has a healthcare-associated infection .Monthly - 1. Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month. 2. Summarize monthly date for each nursing unit buy site and by pathogen (e.g., facility-wide Monthly Infection Report by Site, Facility-Wide Monthly Infection Report by Pathogen, or similar form). ASM #3, the director of nursing, and ASM #4, the interim administrator, were made aware of the above concerns on 11/17/2022 at 12:06 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to continuously employ an infection preventionist (IP) potentially affecting all residents in the survey sample. The findings include: The facility staff failed to employ an infection preventionist from 6/18/22 until 7/25/22. A complaint submitted to the state agency on 6/29/22 alleged that as of 6/18/22, there was no one in the facility certified to fill the role of infection preventionist. On 11/16/22 at 5:32 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated she could not provide evidence that the facility employed an infection preventionist with required credentials from the time the former director of nursing left (6/18/22) until she was hired (7/25/22). On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Infection Preventionist documented, The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices . No further information was presented prior to exit. Complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 38 residents in the survey sample, Resident #27 and Resident #89. 1. The facility staff failed to implement Resident 327's comprehensive care plan for the management of pain. Facility staff administer a as needed pain medication when the residents pain level rating was below the physician parameter of eight, without a pain assessment and without attempting non-pharmacological interventions on multiple occasions during April, May and June 2021. 2. a. The facility staff failed to implement Resident #89's comprehensive care plan for treatment of a pressure injury. LPN #6 was observed cleaning Resident #89's left buttock wound using a piece of gauze wiping the wound from top to bottom and then wiped back up the wound using the same gauze. 2.b. The facility staff failed to implement the comprehensive care plan for the care of Resident #89's indwelling catheter and urine collection bag. Resident #89's Foley catheter bag was placed by staff onto the resident's bed while the resident was lying in the bed. Urine was observed traveling up towards the resident, instead of draining down towards the collection bag. The findings include: 1. Resident #27 was readmitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic pain, high blood pressure and rheumatoid arthritis (A chronic, destructive disease characterized by joint inflammation.) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/22/2021, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The comprehensive care plan dated 7/20/2015 and reviewed on 3/9/2021, documented in part, Potential for pain (Pain to lower back 9/28/18). The Approaches documented in part, Assess location , frequency, duration and intensity of pain as indicated and report increased pain trend to physician. Attempt non-pharmacologic pain relief measures such as repositioning and back rubs as residents allows. Administer medication as ordered. The physician orders dated, 7/11/2020, documented in part, Norco (an opioid with Tylenol used to treat pain) (2) 5-325 tablet, take 1/2 tablet by mouth every 6 hours as needed for pain (8-10) [8 to 10 on a pain scale of 0 to 10, ten meaning the worse pain ever and zero meaning no pain]. The April 2021 MAR (medication administration record) for Resident #27 documented the above physician order for Norco. The MAR documented the Norco was administered on the following dates and times and documented the following regarding the administration of the Norco: 4/1/2021 at 8:32 p.m. - There was no evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/2/2021 at 11:34 p.m. - c/o (complained of) aching pain in BLE (bilateral lower extremity) 7/10 [pain rating of seven out of ten]. 4/3/2021 at 6:51 p.m. - c/o of back and LE (lower extremity) pain 6/10. 4/6/2021 at 11:52 p.m. - c/o aching pain in right leg and knee, 7/10. 4/7/2021 at 9:32 a.m. - Resident complains of leg pain. 4/7/2021 at 8:06 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/8/2021 at 12:10 p.m. - Resident complains of bilateral leg pain unrelieved by laying down. 4/9/2021 at 6:07 p.m. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/10/2021 at 10:42 a.m. - c/o of back pain, 7/10, refused repositioning. 4/10/2021 at 6:06 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/11/2021 at 12:40 a.m. - c/o of aching pain in right leg, 7/10, repositioning ineffective. 4/11/2021 at 10:21 p.m. - PRN (as needed) administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/13/2021 at 6:42 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/14/2021 at 9:00 p.m. - Resident requested for pain. Non-pharmacological interventions without relief. 4/15/2021 at 3:51 p.m. - c/o right leg pain 7/10, repositioning ineffective. 4/16/2021 at 5:49 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/17/2021 at 12:38 p.m. c/o aching pain in right leg. 7/10, repositioning ineffective. 4/17/2021 at 11:39 p.m. - c/o pain reposition not effective. 4/18/2021 at 6:43 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/19/2021 at 1:08 a.m. - c/o pain reposition not effective. 4/22/2021 at 6:29 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/23/2021 at 6:27 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/26/2021 at 5:50 p.m. - c/o right leg pain, 7/10, repositioning ineffective. 4/27/2021 at 12:34 a.m. - c/o pain reposition not effective. 4/27/2021 at 8:24 p.m. - Resident requested for right side hip pain, 7/10, No relief with repositioning. 4/28/2021 at 1:49 p.m. - c/o right leg pain, repositioning ineffective. 4/28/2021 at 7:54 p.m. - Resident requested for right hip and leg pain, 7/10. No relief with repositioning. PRN med given per order. 4/29/2021 at 1:41 p.m. - c/o of right leg pain, 7/10, repositioning ineffective. 4/29/2021 at 10:46 p.m. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. The May 2021 MAR (medication administration record) for Resident #27 documented the above physician order for Norco. The MAR documented the Norco was administered on the following dates and times and documented the following regarding the administration of the Norco: 5/1/2021 at 1:22 a.m. - c/o pain reposition not effective. 5/2/2021 at 6:24 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/4/2021 at 1:43 a.m. - c/o pain repositioning not effective. 5/4/2021 at 9:33 a.m. - PRN administered - pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/6/2021 at 1:11 a.m. - c/o pain reposition not effective. 5/6/2021 at 6:26 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/7/2021 at 9:45 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/10/2021 at 12:22 a.m. c/o aching pain in right hi, 7/10. Repositioning ineffective. 5/10/2021 at 8:12 p.m. PRN administered, pain. There was no evidence of a pain assessment or non-pharmacological interventions prior to the administration of Norco. 5/11/2021 at 8:26 p.m. - Resident requested for pain in hips and back. No relief with repositioning. 5/12/2021 at 11:36 p.m. - C/o pain reposition not effective. 5/13/2021 at 10:09 p.m. - PRN administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/14/2021 at 3:38 p.m. - Resident requested for pain in hips and back, 7/10. No relief in repositioning. 5/14/2021 at 9:42 p.m. - Resident requested for pain in back and hips 7/10. No relief with repositioning. 5/15/2021 at 6:33 p.m. - PRN administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/16/2021 at 5:14 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/17/2021 at 8:21 p.m. - Resident requested for pain in back and hips 7/10. No relief with repositioning. 5/18/2021 at 8:29 p.m. - PRN administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/20/2021 at 12:38 p.m. - c/o pain reposition not effective. 5/21/2021 at 5:41 p.m. - C/o pain reposition not effective. 5/21/2021 at 6:43 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/22/2021 at 10:31 p.m. - Resident requested for hip and back pain 7/10. no relief with repositioning. 5/24/2021 at 4:20 p.m. - c/o r (right) leg pain repositioning refused. There was no documented evidence of a pain assessment prior to the administration of Norco. 5/25/2021 at 4:56 p.m. - Resident requested for pain in back and hips, no relief with repositioning. 5/26/2021 at 12:43 a.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment prior to the administration of Norco. 5/26/2021 at 11:54 p.m. C/o pain reposition not effective. There was no documented evidence of a pain assessment prior to the administration of Norco. 5/27/2021 at 8:11 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/29/2021 at 6:14 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/30/2021 at 2:38 p.m. - c/o generalized pain. Repositioned with no relief. The June 2021 MAR (medication administration record) for Resident #27 documented the above physician order for Norco. The MAR documented the Norco was administered on the following dates and times and documented the following regarding the administration of the Norco: 6/1/2021 at 6:16 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/3/2021 at 2:08 p.m. - c/o generalized pain rated at 7. Repositioned with no relief. 6/7/2021 at 3:30 p.m. - c/o LE (lower extremity) and hip pain, 7/10. Unrelieved by repositioning or diversional activities. 6/8/2021 at 10:50 p.m. - Resident requested for pain in right hip, 7/10. Unrelieved by repositioning. 6/9/2021 at 8:12 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/10/2021 at 5:02 p.m. - C/o pain reposition not effective. 6/11/2021 at 1:00 a.m. - C/o pain reposition not effective. 6/12/2021 at 6:27 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/13/2021 at 12:49 a.m. - C/o pain reposition not effective. 6/17/2021 at 12:35 a.m. - C/o pain reposition not effective. 6/17/2021 at 5:45 p.m. - c/o of back and hip pain, 7/10. Unrelieved by repositioning or diversional activities. 6/18/2021 at 6:39 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/21/2021 at 12:13 p.m. - c/o right leg pain, refused repositioning. 6/21/2021 at 9:58 p.m. - c/o L (left) hip pain, 7/10. Unrelieved by repositioning or diversional activities. 6/22/2021 at 8:25 p.m. - Resident requested for right hip and leg pain, 7/10. No relief with repositioning. 6/23/2021 at 11:55 a.m. - c/o right leg pain repositioning ineffective. 6/25/2021 at 5:32 p.m. - Resident requested for right hip and leg pain, 7/10. No relief with repositioning. 6/26/2021 at 6:49 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/27/2021 at 6:37 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/28/2021 at 4:16 p.m. - c/o R (right) knee pain, 7/10. Unrelieved by repositioning or diversional activities. An interview was conducted with LPN (licensed practical nurse) #2 on 6/30/2021 at 8:55 a.m., regarding the purpose of the comprehensive care plan. LPN #2 stated it's the order to take care of our residents. When asked if the comprehensive care plan should be followed, LPN #2 stated, yes, it's to give the best care that we can. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 6/30/2021 at 9:08 a.m. When asked the purpose of the care plan is, ASM #2 stated it directs the care for our resident. To provide the staff with the information how to care for your resident. A copy of the facility policy for implementing the care plan was requested on 6/30/2021 at 8:49 a.m. from ASM #3, the director of compliance. According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . (3) ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/30/2021 at 12:56 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 511. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/002670.htm. (3) Fundamentals of Nursing [NAME] & [NAME] 2007 [NAME] Company Philadelphia pages 65-77. 2. a. The facility staff failed to implement Resident #89's comprehensive care plan for treatment of a pressure injury. LPN #6 was observed cleaning Resident #89's left buttock wound using a piece of gauze wiping the wound from top to bottom and then wiped back up the wound using the same gauze. Resident #89 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: diabetes, benign prostatic hypertrophy (an enlarged prostate) (1), and psychotic disorders (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions.) (2) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/13/2021, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance for most of his activities of living except eating in which he required supervision after set up assistance was provided. In Section M - Skin Conditions, the resident was coded as having a stage 3 pressure injury. (According to National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Stage 3 is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) (3) The comprehensive care plan dated, 5/20/2021, documented in part, Problem/Need: Potential for further impaired skin integrity. admitted with wound to sacrum (pressure ulcer d/c'd [discharged ] to hospital 6/1/2021 readmitted s/p [status post] debridement of wound). Non-compliant with positioning at times. The Approaches documented in part, Monitor wound status and report any decline to MD (medical doctor). Administer treatments as ordered. Assess impaired area for s/s (signs and symptoms) of infection i.e., redness, swelling, fever, and any foul smelling odor or drainage. Report any abnormalities to physician. Observation was made of Resident #89 receiving wound care by LPN (licensed practical nurse) # 6 on 6/29/2021 at 1:47 p.m. Observation revealed Resident #89 with two pressure sore areas, one on each buttock. Per the clinical record Resident #89 recently had a closure of his pressure injuries on both buttocks completed. LPN # 6 prepared the supplies and positioned Resident # 89 for his wound care. She proceeded to clean the resident's wound on the right buttock with a gauze pad and wound cleanser. LPN # 6 did not change gloves and proceeded to clean the left buttock with a gauze and wound cleanser. Observation revealed LPN #6 wiped down the left buttock wound from top to bottom and then wiped back up the wound, with the same gauze. Observation revealed the right buttock still had four sutures in place and the wound was partially open. The left buttock had three sutures with the wound being partially open. The edges of the wound did not meet. LPN #6 proceeded to apply the prescribed dressing, a 4x4 gauze covered with an abdominal pad and paper tape. An interview was conducted with LPN (licensed practical nurse) #2 on 6/30/2021 at 8:55 a.m. When asked the purpose of the comprehensive care plan, LPN #2 stated it's the order to take care of our residents. When asked if the comprehensive care plan should be followed, LPN #2 stated, yes, it's to give the best care that we can. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 6/30/2021 at 9:08 a.m. When asked the purpose of the comprehensive care plan is, ASM #2 stated it directs the care for our resident. To provide the staff with the information how to care for your resident. A copy of the facility policy for implementing the care plan was requested on 6/30/2021 at 8:49 a.m. from ASM #3, the director of compliance. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/29/2021 at 5:40 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (2) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=psychotic+disorders. (3) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ 2.b. The facility staff failed to implement the comprehensive care plan for the care of Resident #89's indwelling catheter and urine collection bag. Resident #89's Foley catheter bag was placed by staff onto the resident's bed while the resident was lying in the bed. Urine was observed traveling up towards the resident, instead of draining down towards the collection bag. The comprehensive care plan dated, 5/20/2021, documented in part, Problem/Need: Potential for injury/infection related to presence of indwelling catheter, d/c (discontinued 6/1. 6/7/21 suprapubic catheter. The Approaches documented in part, Assist with catheter care per facility protocol. Encourage resident to allow securing of catheter to thigh to prevent pulling on tubing and to keep collection bag below bladder level. Check tubing for kinks. Provide assistance during transfer and ambulation as needed. Observation was made on 6/29/2021 at 1:47 p.m. of LPN (licensed practical nurse) # 6 performing wound care for Resident #89. LPN #6 gathered her supplies. She then assisted the resident with positioning himself in the bed for the dressing change. Resident #89 was sitting on the side of the bed. LPN #6 was observed lifting the residents indwelling catheter urine collection bag and placed it onto the bed. She then assisted Resident #89 to a lying position on the bed. Observation revealed Resident #89's legs on top of the collection bag. Urine was observed traveling up towards the resident, instead of draining down towards the collection bag. LPN #6 then performed the dressing change. After the dressing was completed, she assisted Resident #89 into a sitting position on the side of the bed and then lowered the Foley catheter collection bag to the side of the bed frame. Observation revealed a large, approximately six by three inch, wet spot on the resident's trousers, on the left side of his right knee. An interview was conducted with LPN #6 immediately after the dressing change regarding the placement of a Foley catheter urine collection bag. LPN #6 stated, When the resident is in bed, I hook it to the side of the bed at the bed frame so the urine will drain down. When asked why she put the urine collection bag on the bed, LPN #6 stated she should have put it on the other side of the bed on the bed frame. When asked why that is done, LPN #6 stated it's for infection control. LPN #6 was informed of the above observation of the collection bag placed on the bed and the urine flowing up the catheter towards the resident's bladder. LPN #6 stated, That would be dirty urine going back up and being an infection problem. An interview was conducted with LPN (licensed practical nurse) #2 on 6/30/2021 at 8:55 a.m. When asked the purpose of the comprehensive care plan, LPN #2 stated it's the order to take care of our residents. When asked if the care plan should be followed, LPN #2 stated, yes, it's to give the best care that we can. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 6/30/2021 at 9:08 a.m. When asked the purpose of the comprehensive care plan is, ASM #2 stated it directs the care for our resident. To provide the staff with the information how to care for your resident. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/29/2021 at 5:40 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (2) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=psychotic+disorders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide wound care in a manner to promote healing and prevent infection for one of 38 residents in the survey sample, Resident #89. LPN #6 failed to change gloves between cleaning Resident #89's right and left buttock wound and wiped down the left buttock wound from top to bottom and then wiped back up the wound using the same gauze. The findings include: Resident #89 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: diabetes, benign prostatic hypertrophy (an enlarged prostate) (1), and psychotic disorders (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions.) (2) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/13/2021, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance for most of his activities of living except eating in which he required supervision after set up assistance was provided. In Section M - Skin Conditions, the resident was coded as having a stage 3 pressure injury. (According to National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Stage 3 is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) (3) Observation was made of Resident #89 receiving wound care by LPN (licensed practical nurse) # 6 on 6/29/2021 at 1:47 p.m. Observation revealed Resident #89 with two pressure sore areas, one on each buttock. Per the clinical record Resident #89 recently had a closure of his pressure injuries on both buttocks completed. LPN # 6 prepared the supplies and positioned Resident # 89 for his wound care. She proceeded to clean the resident's wound on the right buttock with a gauze pad and wound cleanser. LPN # 6 did not change gloves and proceeded to clean the left buttock with a gauze and wound cleanser. Observation revealed LPN #6 wiped down the left buttock wound from top to bottom and then wiped back up the wound, with the same gauze. Observation revealed the right buttock still had four sutures in place and the wound was partially open. The left buttock had three sutures with the wound being partially open. The edges of the wound did not meet. LPN #6 proceeded to apply the prescribed dressing, a 4x4 gauze covered with an abdominal pad and paper tape. An interview was conducted with LPN #6 on 6/29/2021 at approximately 2:10 p.m., right after the wound care was completed. When asked if you can wash a wound and then go back over the wound with the same gauze, LPN #6 stated, No. When asked why you cannot wipe down and then go back up with the same gauze, LPN #6 stated Because of infection control. Wiping the dirty right back up on the wound is not good. The above observation was shared with LPN #6. An interview was conducted with RN (registered nurse) #3, the assistant director of nursing, on 6292021 at 2:29 p.m. When asked once you clean a wound, can you go back over that same area with the gauze you just used, RN #3 stated, No, Ma'am, because it would be contaminating it and bringing back germs to the area you just cleaned. The above wound care observation was shared with RN #3. The comprehensive care plan dated, 5/20/2021, documented in part, Problem/Need: Potential for further impaired skin integrity. admitted with wound to sacrum (pressure ulcer d/c'd [discharged ] to hospital 6/1/2021 readmitted s/p [status post] debridement of wound). Non compliant with positioning at times. The Approaches documented in part, Monitor wound status and report any decline to MD (medical doctor). Administer treatments as ordered. Assess impaired area for s/s (signs and symptoms) of infection i.e., redness, swelling, fever, and any foul smelling odor or drainage. Report any abnormalities to physician. The facility policy, Pressure Ulcer, Prevention/Care of failed to evidence documentation of how a dressing is to be performed. ASM (administrative staff member) #3, the director of compliance, presented a documented, In-Service Training Report dated 5/21/2020 for Yearly Skills Evaluation for LPN #6. The second entitled, Wound Care and Dressing Changes documented in part, Create a clean area (paper towel on bedside table) for each different wound that you will be dressing to not cross contaminate the direct wounds. Change gloves between each different wound and wash hands. Fundamentals of Nursing Made Incredibly Easy, [NAME], [NAME] & [NAME], 2007, page 428. When cleaning, be sure to move from the least-contaminated area to the most-contaminated area. For a linear shaped wound, such as an incision, gently wipe from top to bottom in one motion, starting directly over the wound and moving outward. For an open wound, such as a pressure ulcer, gently wipe in concentric circles, again starting directly over the wound and moving outward. Us a separate gauze pad each time the wound is cleaned. Discard the gauze pad for each wiping motion; repeat the procedure until you've cleaned the entire wound. Dry the wound with 4 X 4 gauze pads, using the same procedure as for cleaning. Discard the used gauze pads in the plastic bag. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/29/2021 at 5:40 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (2) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=psychotic+disorders. (3) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an indwelling catheter consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 38 residents in the survey sample, Resident # 89. The nurse failed to maintain the indwelling catheter collection bag below the resident's bladder. Observation revealed the staff placed Resident #89's Foley catheter bag on the bed while the resident received wound care. Urine was observed flowing up towards the resident and not towards the collection bag. The findings include: Resident #89 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: diabetes, benign prostatic hypertrophy (an enlarged prostate) (1), and psychotic disorders (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there.) (2). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/13/2021, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance for most of his activities of living except eating in which he required supervision after set up assistance was provided. In Section H - Bladder and Bowel, Resident #89 was coded as having an indwelling catheter. Observation was made on 6/29/2021 at 1:47 p.m. of LPN (licensed practical nurse) # 6 performing wound care on Resident #89. LPN #6 gathered her supplies. She then assisted the resident to position himself in the bed for the dressing change. The resident was sitting on the side of the bed. LPN #6 proceeded to lift the indwelling catheter urine collection bag onto the bed. She then assisted the resident to lie down with his legs on top of the collection bag. Urine was observed to travel up towards the resident and not towards the collection bag. LPN #6 proceeded to perform the dressing change. After the dressing was done, she assisted the resident into a sitting position on the side of the bed and then lowered the collection bag to the side of the bed frame. Noted on the resident's left side of his right knee was a large, approximately six by three inch, wet spot on his trousers. An interview was conducted with LPN #6 immediately after the dressing change. When asked where the urine collection bag is supposed to be, LPN #6 stated when the resident is in bed, I hook it to the side of the bed at the bed frame. When asked why we do that, LPN #6 stated, So the urine will drain down. When asked why she put the urine collection bag on the bed, LPN #6 stated she should have put it on the other side of the bed on the bed frame. When asked why that is done, LPN #6 stated it's for infection control. When the observation of placing the collection bag on the bed and the observation of the urine flowing up the catheter towards the resident's bladder, LPN #6 stated, That would be dirty urine going back up and being an infection problem. An interview was conducted with RN (registered nurse) #3, the assistant director of nursing, on 6/29/2021 at 2:29 p.m. When asked where an indwelling urine collection bag should be stored, RN #3 stated it should be not on the floor but on the bed frame of the bed, it has to be below the leg or bladder. When asked if a resident is lying on the bed, should the collection bag be placed on the bed, RN #3 stated, No, it's not going to be able to drain adequately and you run the risk of the urine back flowing up to the bladder, an infection control problem. The comprehensive care plan dated, 5/20/2021, documented in part, Problem/Need: Potential for injury/infection related to presence of indwelling catheter, d/c (discontinued 6/1. 6/7/21 suprapubic catheter. The Approaches documented in part, Assist with catheter care per facility protocol. Encourage resident to allow securing of catheter to thigh to prevent pulling on tubing and to keep collection bag below bladder level. Check tubing for kinks. Provide assistance during transfer and ambulation as needed. The facility policy, Catheter Care, Indwelling Catheter documented in part, 11. Position resident comfortably, drainage bag below bladder. According to Fundamentals of Nursing [NAME] and [NAME] Eighth Edition 2006, [NAME] Company, page 757, titled Renal and Urinary Disorders, under the heading Management of a Patient with an Indwelling Catheter and Closed Drainage System the subheading: Maintaining a closed drainage system: 2. Maintain an unobstructed urine flow. b. Urine should not be allowed to collect in tubing because free flow of urine must be maintained to prevent urinary tract infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing. c. Keep the bag off the floor to prevent bacterial contamination. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/29/2021 at 5:40 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (2) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=psychotic+disorders.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to store, and prepare, food in accordance with professional standards for food service. The facility staff failed to maintain the fryer in a sanitary manner after use the previous evening and failed to dispose of expired or opened food during the facility task- kitchen observation on 6/28/21 at 11:30 AM. The findings include: On 6/28/21 at 11:30 AM, an observation was conducted in the main kitchen. The deep fryer was observed with food liked appearing particles on the basket drain area and (two) 16-ounce boxes of cornstarch, both open to the air were observed on shelf next to sink. An interview was conducted on 6/28/21 at 11:45 AM with OSM (other staff member) #3, the dietary cook. OSM #3 was asked when the fryer was last used. OSM #3 stated, I'm not sure. I wasn't here yesterday, but probably yesterday. The fryer was noted to be off and not in use for the lunch meal. When asked if the fryer had been used for breakfast, OSM #3 stated, No, we don't use it for breakfast. When asked if they would have used it for supper the previous evening, OSM #3 stated, Yes, probably for chicken or French fries. When asked if the fryer should be cleaned after use, OSM #3 stated, Yes, it should be cleaned after each use. We empty the fryer and clean it on Monday's. When asked about the two cornstarch boxes that were open to air on the shelf next to the sink, OSM #3 stated, They should not be opened like that. I will throw them away right now. The facility's Equipment policy revised 9/2017, documents in part, All food service equipment, will be clean, sanitary and in proper working order. All food contact equipment will be cleaned and sanitized after every use. The facility's Food Storage: Dry Goods and Cold Food policy revised 4/2018, documents in part, All goods will be properly stored in accordance with the FDA (food drug administration) Food Code. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the director of compliance were made aware of the above concerns on 6/29/21 at 5:50 PM. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure pain management was provided consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 38 residents in the survey sample, Resident #27. The facility staff failed to complete a pain assessment of Resident #27's pain, prior to the administration of a pain medication on multiple occasions in April, May and June 2021. The findings include: The facility policy, Pain Assessment documented in part, Purpose: Establish uniform guidelines concerning pain assessment and management. Definition: Pain can be described as an unpleasant sensory or emotional experience. Procedure: 1. Pain Assessments: .b. A routine pain assessment will include intensity of pain (level of pain) and location. Nonpharmacological measures and their effectiveness may be assessed and discussed with the resident. c. A pain assessment may include the resident's description of the pain and any contributing factors they report. d. The Faces Scale or a numerical scale of 0 -10, with 0 being no pain at all and 10 being the worst pain experienced will be assessed and documented with the pain assessment prior to administering medications and during reassessment .f. Should nonpharmacological interventions be ineffective or refused this should be documented. g. Pain medications should be administered per the physician orders. Resident #27 was readmitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic pain, high blood pressure and rheumatoid arthritis (A chronic, destructive disease characterized by joint inflammation. Symptoms are varied, often including fatigue, low grade fever, loss of appetite, morning stiffness, tender, painful swelling of two or more joints, most commonly in fingers, ankles, feet, hips and shoulders.) (1) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/22/2021, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. In Section J 0100 the resident was coded as receiving both scheduled and as needed pain medication. It was coded that the resident did not receive any non-medication interventions for pain. Resident #27 was coded as having pain occasionally and coded that it limits her day-to-day activities. The pain intensity was coded as a 10. Observation was made of Resident #27 on 6/28/2021 at 4:30 p.m. She was in her wheelchair asking for her pain medication. ASM (administrative staff member) #1, the administrator, was observed telling the nurse that Resident #27 wanted her pain medication. ASM #1 was then observed telling Resident #27 he had spoken to the nurse and it wasn't time for her to receive her pain medication. The nurse would bring it when it was time. The physician orders dated, 7/11/2020, documented in part, Norco (an opioid with Tylenol used to treat pain) (2) 5-325 tablet, take 1/2 tablet by mouth every 6 hours as needed for pain (8-10) (8 to 10 on a pain scale of 0 to 10, ten meaning the worse pain every in and zero meaning no pain). The April 2021 MAR (medication administration record) documented the above physicians order for Norco. On the following dates and times Resident #27's MAR failed to evidence a pain assessment was completed prior to the administration of the Norco: 4/1/2021 at 8:32 p.m., 4/6/2021 at 11:52 p.m., 4/7/2021 at 9:32 a.m., 4/7/2021 at 8:06 p.m.,4/8/2021 at 12:10 p.m.,4/9/2021 at 6:07 p.m.,4/10/2021 at 6:05 p.m., 4/11/2021 at 10:21 p.m.,4/13/2021 at 6:42 p.m., 4/14/2021 at 9:00 p.m.,4/16/2021 at 5:49 p.m., 4/17/2021 at 11:39 p.m., 4/18/2021 at 6:43 p.m.,4/19/2021 at 1:08 a.m., 4/22/2021 at 6:29 p.m., 4/23/2021 at 6:27 p.m., 4/27/2021 at 12:34 p.m., 4/28/2021 at 1:49 p.m., and 4/29/2021 at 10:46 p.m. The May 2021 MAR documented the above physicians order for Norco. On the following dates and times Resident #27's MAR failed to evidence a pain assessment was completed prior to the administration of the Norco: following dates and times:5/1/2021 at 1:22 a.m., 5/2/2021 at 6:24 p.m., 5/4/2021 at 1:43 a.m., 5/4/2021 at 9:33 p.m., 5/6/2021 at 1:11 a.m., 5/6/2021 at 6:26 p.m., 5/7/2021 at 9:45 p.m., 5/10/2021 at 12:22 a.m., 5/10/2021 at 8:12 p.m., 5/11/2021 at 8:26 p.m., 5/12/2021 at 11:36 p.m., 5/13/2021 at 10:09 p.m., 5/15/2021 at 6:33 p.m., 5/16/2021 at 5:14 p.m., 5/18/2021 at 8:29 p.m., 5/20/2019 at 12:38 p.m., 5/21/2021 at 5:41 a.m., 5/21/2021 at 6:43 p.m., 5/24/2021 at 4:20 p.m., 5/25/2021 at 4:56 p.m., 5/26/2021 at 12:43 a.m., 5/26/2021 a t 11:54 p.m., 5/27/2021 at 8:11 p.m., 5/29/2021 at 6:14 p.m., and 5/30/2021 at 2:38 p.m. The June 2021 MAR documented the above physicians order for Norco. On the following dates and times Resident #27's MAR failed to evidence a pain assessment was completed prior to the administration of the Norco: 6/1/2021 at 6:16 p.m., 6/9/2021 at 8:12 p.m., 6/10/2021 at 5:02 a.m., 6/11/2021 at 1:06 a.m., 6/12/2021 at 6:27 p.m., 6/13/2021 at 12:49 a.m., 6/17/2021 at 12:35 a.m., 6/18/2021 at 6:39 p.m., 6/21/2021 at 12:13 p.m., 6/23/2021 at 11:55 a.m., 6/26/2021 at 6:49 p.m., and 6/27/2021 at 6:37 p.m. Review of the nurses notes failed to reveal any documentation of pain assessments for the above listed dates and times. The comprehensive care plan dated 7/20/2015 and reviewed on 3/9/2021, documented in part, Potential for pain (Pain to lower back 9/28/18). The Approaches documented in part, Assess location , frequency, duration and intensity of pain as indicated and report increased pain trend to physician. Attempt non-pharmacologic pain relief measures such as repositioning and back rubs as residents allows. Administer medication as ordered. An interview was conducted with LPN (licensed practical nurse) #2, on 6/30/2021 at 8:55 a.m. When asked about the process staff follows when a resident complains of pain, LPN #2 stated, a nurse should assess the pain, find out on the pain scale what level their pain is, and try to reposition the resident or other non-pharmacological interventions. If they don't work, you see if there is a medication you can give them. The nurse will give medication per the physician order as some have parameters of when to give. Then you follow up with the resident to see if the medication worked. The above order for Norco was reviewed with LPN #2. When asked if Resident #27's pain was assessed prior to administering the prescribed pain medication on the dates listed above, LPN #2 stated no. An interview was conducted with ASM #2, the director of nursing, on 6/30/2021 at 9:08 a.m. When asked about the process staff follows when a resident complains of pain, ASM #2 stated, First thing the nurse does is to assess the resident and their pain. Where is it at, what does it feel like, and if they can, ask them to rate it on the pain scale? First, the nurse should try non-pharmacological interventions such as repositioning, and if that doesn't work they should go to the physician orders to see what they have ordered. The above MARS for April May and June and the Norco order was reviewed with ASM #2. When asked if Resident #27's pain was assessed on the dates and times listed above, ASM #2 stated, no. Fundamentals of Nursing, 6th Edition, [NAME] and [NAME], 2005, pages 1239-1287, Nurses need to approach pain management systematically to understand a client's pain and to provide appropriate intervention it is necessary to monitor pain on a consistent basis Assessment of common characteristics of pain helps the nurse form an understanding of the type of pain, its pattern, and types of interventions that may bring relief Onset and duration Location Intensity Quality Pain Pattern Relief Measures Contributing Symptoms Pain therapy requires an individualized approach Pain Management Practices, Volume 6, Symptom Management Acute Pain, National Institute for Nursing Research, page 6, documents, in part: The primary responsibility for the assessment and management of pain belongs to the nurse. (According to the National Institutes for Health), the nurse plays a central role in pain management and should coordinate the activities. Sound assessment is necessary for implementation of appropriate pain management interventions. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/30/2021 at 12:56 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 511. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/002670.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one of 38 residents in the survey sample was free of unnecessary medications, Resident #27. On multiple occasions during April, May and June 2021, the facility staff failed to ensure Resident #27 was free from unnecessary medication, as evidenced by the staffs failure to complete a pain assessment, and failure to attempt/offer non-pharmacological interventions prior to administering the physician prescribed as needed pain medication Norco to Resident #27, and as evidenced by staff administering the medication for documented/reported pain levels of 7, which were below the physician ordered parameter of eight (8) for administration of the medication. The findings include: Resident #27 was readmitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic pain, high blood pressure and rheumatoid arthritis (A chronic, destructive disease characterized by joint inflammation. Symptoms are varied, often including fatigue, low grade fever, loss of appetite, morning stiffness, tender, painful swelling of two or more joints, most commonly in fingers, ankles, feet, hips and shoulders.) (1). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/22/2021, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. In Section J 0100 the resident was coded as receiving both scheduled and as needed pain medication. It was coded that the resident did not receive any non-medication interventions for pain. Resident #27 was coded as having pain occasionally and it limits her day-to-day activities. The pain intensity was coded as a 10. Observation was made of Resident #27 on 6/28/2021 at 4:30 p.m. She was in her wheelchair asking for her pain medication. ASM (administrative staff member) #1, the administrator, was observed telling the nurse that Resident #27 wanted her pain medication. ASM #1 was then observed telling Resident #27 he had spoken to the nurse and it wasn't time for her to receive her pain medication. The nurse would bring it when it was time. The physician orders dated, 7/11/2020, documented in part, Norco (an opioid with Tylenol used to treat pain) (2) 5-325 tablet, take 1/2 tablet by mouth every 6 hours as needed for pain (8-10)(8 to 10 on a pain scale of 0 to 10, ten meaning the worse pain every in and zero meaning no pain). The April 2021 MAR (medication administration record) documented the above physician order for Norco. Resident #27's April MAR documented the Norco was administered on the following dates and times without a pain assessment prior to, and or without any attempt of non-pharmacological intervention prior to administration and or for a pain level below the physician ordered pain level parameter of eight (8): 4/1/2021 at 8:32 p.m.- There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/2/2021 at 11:34 p.m. - c/o (complained of) aching pain in BLE (bilateral lower extremity) 7/10 [pain level seven out of possible ten, with 0 being no pain and ten being the worst pain]. 4/3/2021 at 6:51 p.m. - c/o of back and LE (lower extremity) pain 6/10. 4/6/2021 at 11:52 p.m. - c/o aching pain in right leg and knee, 7/10. 4/7/2021 at 9:32 a.m. - Resident complains of leg pain. 4/7/2021 at 8:06 p.m. - There was no documented evidence of a pain assessment or any attempt to provide non-pharmacological interventions prior to the administration of Norco. 4/8/2021 at 12:10 p.m. - Resident complains of bilateral leg pain unrelieved by laying down. There was no documentation of a pain assessment or pain level. 4/9/2021 at 6:07 p.m. There was no documented evidence of a pain assessment or non-pharmacological interventions prior to the administration of Norco. 4/10/2021 at 10:42 a.m. - c/o of back pain, 7/10, refused repositioning. 4/10/2021 at 6:06 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/11/2021 at 12:40 a.m. - c/o of aching pain in right leg, 7/10, repositioning ineffective. 4/11/2021 at 10:21 p.m. - PRN (as needed) administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/13/2021 at 6:42 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/14/2021 at 9:00 p.m. - Resident requested for pain. Non-pharmacological interventions without relief. There was no documented evidence of a pain assessment. 4/15/2021 at 3:51 p.m. - c/o right leg pain 7/10, repositioning ineffective. 4/16/2021 at 5:49 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/17/2021 at 12:38 p.m. c/o aching pain in right leg. 7/10, repositioning ineffective. 4/17/2021 at 11:39 p.m. - c/o pain reposition not effective. There was no documented evidence of a pain assessment 4/18/2021 at 6:43 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/19/2021 at 1:08 a.m. - c/o pain reposition not effective. There was no documented evidence of a pain assessment 4/22/2021 at 6:29 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/23/2021 at 6:27 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 4/26/2021 at 5:50 p.m. - c/o right leg pain, 7/10, repositioning ineffective. 4/27/2021 at 12:34 a.m. - c/o pain reposition not effective. There was no documented evidence of a pain assessment 4/27/2021 at 8:24 p.m. - Resident requested for right side hip pain, 7/10, No relief with repositioning. 4/28/2021 at 1:49 p.m. - c/o right leg pain, repositioning ineffective. There was no documented evidence of a pain assessment. 4/28/2021 at 7:54 p.m. - Resident requested for right hip and leg pain, 7/10. No relief with repositioning. PRN med given per order. 4/29/2021 at 1:41 p.m. - c/o of right leg pain, 7/10, repositioning ineffective. 4/29/2021 at 10:46 p.m. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. The May 2021 MAR (medication administration record) documented the above physician order for Norco. Resident #27's May 2021 MAR documented the Norco was administered on the following dates and times without a pain assessment prior to, and or without any attempt of non-pharmacological intervention prior to administration and or for a pain level below the physician ordered pain level parameter of eight (8): 5/1/2021 at 1:22 a.m. - c/o pain reposition not effective. There was no documented evidence of a pain assessment 5/2/2021 at 6:24 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/4/2021 at 1:43 a.m. - c/o pain repositioning not effective. There was no documented evidence of a pain assessment 5/4/2021 at 9:33 a.m. - PRN administered - pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/6/2021 at 1:11 a.m. - c/o pain reposition not effective. There was no documented evidence of a pain assessment 5/6/2021 at 6:26 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/7/2021 at 9:45 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/10/2021 at 12:22 a.m. c/o aching pain in right hi, 7/10. Repositioning ineffective. 5/10/2021 at 8:12 p.m. PRN administered, pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/11/2021 at 8:26 p.m. - Resident requested for pain in hips and back. No relief with repositioning. There was no documented evidence of a pain assessment 5/12/2021 at 11:36 p.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment 5/13/2021 at 10:09 p.m. - PRN administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/14/2021 at 3:38 p.m. - Resident requested for pain in hips and back, 7/10. No relief in repositioning. 5/14/2021 at 9:42 p.m. - Resident requested for pain in back and hips 7/10. No relief with repositioning. 5/15/2021 at 6:33 p.m. - PRN administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/16/2021 at 5:14 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/17/2021 at 8:21 p.m. - Resident requested for pain in back and hips 7/10. No relief with repositioning. 5/18/2021 at 8:29 p.m. - PRN administered pain. There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/20/2021 at 12:38 p.m. - c/o pain reposition not effective. There was no documented evidence of a pain assessment. 5/21/2021 at 5:41 p.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment. 5/21/2021 at 6:43 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/22/2021 at 10:31 p.m. - Resident requested for hip and back pain 7/10. no relief with repositioning. 5/24/2021 at 4:20 p.m. - c/o r (right) leg pain repositioning refused. There was no evidence of a pain assessment prior to the administration of Norco. 5/25/2021 at 4:56 p.m. - Resident requested for pain in back and hips, no relief with repositioning. There was no documented evidence of a pain assessment. 5/26/2021 at 12:43 a.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment prior to the administration of Norco. 5/26/2021 at 11:54 p.m. C/o pain reposition not effective. There was no documented evidence of a pain assessment prior to the administration of Norco. 5/27/2021 at 8:11 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/29/2021 at 6:14 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 5/30/2021 at 2:38 p.m. - c/o generalized pain. Repositioned with no relief. There was no documented evidence of a pain assessment. The June 2021 MAR (medication administration record) documented the above physician order for Norco. Resident #27's June 2021 MAR documented the Norco was administered on the following dates and times without a pain assessment prior to, without any attempt of non-pharmacological intervention prior to administration and or for a pain level below the physician ordered pain level parameter of eight (8): 6/1/2021 at 6:16 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/3/2021 at 2:08 p.m. - c/o generalized pain rated at 7. Repositioned with no relief. 6/7/2021 at 3:30 p.m. - c/o LE (lower extremity) and hip pain, 7/10. Unrelieved by repositioning or diversional activities. 6/8/2021 at 10:50 p.m. - Resident requested for pain in right hip, 7/10. Unrelieved by repositioning. 6/9/2021 at 8:12 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/10/2021 at 5:02 p.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment. 6/11/2021 at 1:00 a.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment. 6/12/2021 at 6:27 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/13/2021 at 12:49 a.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment. 6/17/2021 at 12:35 a.m. - C/o pain reposition not effective. There was no documented evidence of a pain assessment. 6/17/2021 at 5:45 p.m. - c/o of back and hip pain, 7/10. Unrelieved by repositioning or diversional activities. 6/18/2021 at 6:39 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/21/2021 at 12:13 p.m. - c/o right leg pain, refused repositioning. There was no documented evidence of a pain assessment. 6/21/2021 at 9:58 p.m. - c/o L (left) hip pain, 7/10. Unrelieved by repositioning or diversional activities. 6/22/2021 at 8:25 p.m. - Resident requested for right hip and leg pain, 7/10. No relief with repositioning. 6/23/2021 at 11:55 a.m. - c/o right leg pain repositioning ineffective. There was no documented evidence of a pain assessment. 6/25/2021 at 5:32 p.m. - Resident requested for right hip and leg pain, 7/10. No relief with repositioning. 6/26/2021 at 6:49 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/27/2021 at 6:37 p.m. - There was no documented evidence of a pain assessment or attempted non-pharmacological interventions prior to the administration of Norco. 6/28/2021 at 4:16 p.m. - c/o R (right) knee pain, 7/10. Unrelieved by repositioning or diversional activities. Review of the nursing notes for April May and June 2021 failed to evidence any documentation of pain assessments and or non-pharmacological interventions attempted for the above. The comprehensive care plan dated 7/20/2015 and reviewed on 3/9/2021, documented in part, Potential for pain (Pain to lower back 9/28/18). The Approaches documented in part, Assess location , frequency, duration and intensity of pain as indicated and report increased pain trend to physician. Attempt non-pharmacological pain relief measures such as repositioning and back rubs as residents allows. Administer medication as ordered. An interview was conducted with LPN (licensed practical nurse) #2, on 6/30/2021 at 8:55 a.m. When asked about the process staff follows when a resident complains of pain, LPN #2 stated, a nurse should assess the pain, find out on the pain scale what level their pain is, and try to reposition the resident or other non-pharmacological interventions. If they don't work, you see if there is a medication you can give them. The nurse will give medication per the physician order as some have parameters of when to give. Then you follow up with the resident to see if the medication worked. The above physician as needed order for Norco was reviewed with LPN #2. When asked if the resident stated their pain level was a 7, should staff administer the Norco medication, LPN #2 stated no, if it's not in the range prescribed by the doctor, you'd have to check with the doctor to see if there was something else to give. An interview was conducted with ASM #2, the director of nursing, on 6/30/2021 at 9:08 a.m. When asked about the process staff follows when a resident complains of pain, ASM #2 stated, First thing the nurse does is to assess the resident and their pain. Where is it at, what does it feel like, and if they can, ask them to rate it on the pain scale? First, the nurse should try non-pharmacological interventions such as repositioning, and if that doesn't work they should go to the physician orders to see what they have ordered. The above physician as needed Norco order was reviewed with ASM #2. When asked if Resident #27 rated their pain level as a seven, should the nurse administer the as needed medication Norco, ASM #2 stated, No, they would have to contact the doctor for another order. Resident #27's above MARS for April May and June 2021 and the as needed Norco order was reviewed with ASM #2. When asked if Resident #27's pain was assessed and if staff attempted non- pharmacological interventions on the dates and times listed above, ASM #2 stated, no. When asked if the nurse should complete a pain assessment and offer non-pharmacological interventions prior to giving a pain medication, ASM #2 stated, Yes. The facility policy, Pain Assessment documented in part, Purpose: Establish uniform guidelines concerning pain assessment and management. Definition: Pain can be described as an unpleasant sensory or emotional experience. Procedure: 1. Pain Assessments: .b. A routine pain assessment will include intensity of pain (level of pain) and location. Nonpharmacological measures and their effectiveness may be assessed and discussed with the resident. c. A pain assessment may include the resident's description of the pain and any contributing factors they report. d. The Faces Scale or a numerical scale of 0 -10, with 0 being no pain at all and 10 being the worst pain experienced will be assessed and documented with the pain assessment prior to administering medications and during reassessment .f. Should nonpharmacological interventions be ineffective or refused this should be documented. g. Pain medications should be administered per the physician orders. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the director of corporate compliance, were made aware of the above findings on 6/30/2021 at 12:56 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 511. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/002670.htm.