**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence documentation of current side rail assessment and consent for one of six residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility failed to evidence an assessment or consent for the use of bed rails. The MDS (minimum data set) assessment was not due at the time of the survey. On the nursing admission assessment dated [DATE] documented R2 being alert and oriented to person, place and time. The assessment documented R2 having weight bearing limitations and and being non-weight bearing on the left extremity. On 7/16/2024 at 2:35 p.m., an interview was conducted with R2 in their room. Bilateral bar shaped rails were observed on the resident's bed. R2 stated that they used the bilateral bar shaped rails when in bed to turn and position and when getting out of bed. R2 stated that they had recently been admitted to the facility and the rails were on the bed when they arrived and they had been using them since admission. R2 stated that they did not recall signing a consent form for the rails but they did want to have them because they used them every day. Review of the clinical record for R2 revealed a Enabler/Physical Restraint/Side Rail Review dated 7/13/24 which failed to evidence an assessment for use, a discussion of the risk and benefits or consent for the use of the bilateral bar shaped rails. An additional observation of R2 was made on 7/17/2024 at 7:59 a.m. R2 was observed in bed with the bilateral bar shaped bed rails in place. On 7/16/2024 at approximately 4:00 p.m., a request was made via written list to ASM (administrative staff member) #1, the administrator, for evidence of a bed rail assessment for R2. On 7/17/2024 at approximately 1:38 p.m., ASM #2, director of nursing, provided a bed rail assessment dated [DATE] at 11:33 a.m. for R2. On 7/17/2024 at 1:34 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident used bed rails the nurse confirmed that the resident wanted to use them and completed an assessment with the resident to make sure they were able to use them safely. She stated that they documented the assessment in the medical record on the computer. She stated that this was done during the admission process. LPN #1 reviewed the Enabler/Physical Restraint/Side Rail Review dated 7/13/24 for R2 and stated that by looking at the assessment they could not say that the resident used bed rails. She stated that the bed rails should have been documented on the assessment and consent should have been documented. On 7/17/2024 at 3:24 p.m., ASM #1, the administrator, ASM #2, director of nursing, ASM #3, assistant administrator, and ASM #4, regional director of clinical services were made aware of the above concern. On 7/17/2024 at 4:28 p.m., OSM (other staff member) #3, the director of rehab provided a physical therapy evaluation and plan of treatment for R2 dated 7/15/2024 and stated that it addressed R2's weight bearing status. She stated that the therapy staff normally explained the risks and benefits of the bed rails, and determined if the resident needed them and documented it in their notes. OSM #3 reviewed the physical therapy evaluation and plan she provided and stated that she did not see where they had educated R2 in the notes. On 7/17/2024 at 4:42 p.m., a follow up interview was conducted with R2. When asked if they had been educated on the risks and benefits of bed rails by facility staff, R2 stated, No. R2 stated that they had used the rails during their previous admission and they thought they were part of the beds. On 7/17/2024 at 4:43 p.m., ASM #1, the administrator was notified that the concern remained. No further information was provided prior to exit. The facility policy Bed rail policy dated 1/25/24 documented in part, If a bed or side rail or bar is used, the facility will: a. Evaluate the potential risks associated with the use of bed rails including the risk of entrapment, prior to bed rail installation using the Bed and Bed Rail Safety Inspection Checklist. b. Evaluate the risk versus benefits of using a bed rail and review them with the resident or if applicable, the resident ' s representative. c. Obtain informed consent for the installation and use of bed rails prior to the installation .

Based on resident interview, staff interview, clinical record review and facility record review, it was determined that the facility staff failed to ensure one of 34 residents were provided the opportunity to participate in the care planning process, Resident #18. The findings include: For Resident #18 (R18), the facility staff failed to evidence inclusion of the resident in the interdisciplinary care planning process. On the most recent MDS (minimum data set), an annual admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 6/1/2023 at 2:09 p.m., an interview was conducted with R18 in their room. R18 stated that they had resided at the facility for about a year. When asked if they were invited to participate in the care planning process, R18 stated that they had never been asked to attend a care plan meeting. R18 stated that they would be interested in attending any meeting that discussed their care and goals because they wanted to be involved in their care at the facility. Review of R18's clinical record failed to evidence documentation of care plan meeting notes or invitations provided to R18. On 6/1/2023 at 3:18 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing, for evidence of R18 being invited and/or notified of the care plan meetings. On 6/1/2023 at 3:44 p.m., ASM #2 stated that they did not have evidence of a care plan invitation/notification for R18 to provide. On 6/2/2023 at 9:05 a.m., an interview was conducted with OSM (other staff member) #6, the director of social services. OSM #6 stated that they set up the care plan meetings every quarter and annually. OSM #6 stated that they normally provided telephone notice to the residents responsible party if applicable and spoke to the residents in person and gave them an invitation letter. OSM #6 stated that they documented the invitation in the progress notes, however they did not have evidence of that for R18. OSM #6 stated that they were not having care plan meetings as often for a while because there really was no nursing department so they were meeting with the MDS coordinator. OSM #6 stated that they had met with R18's sister a couple of times and met with R18 directly a couple of times in the past. The facility policy, Comprehensive Care Planning Policy with a revision date of 7/19/2019 documented in part, .The Interdisciplinary Care Planning Team may consist of: 1. The resident, the resident's family and/or the resident's legal representative The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting. The letter of requested participation (original) is presented to the resident at least five (5) days prior to the date of conference. A designated time of meeting is given to each resident. (Those residents who have been deemed legally incompetent or has documentation in their medical record, as medically incompetent by their attending physician would be exempt from this procedure.) A copy of the letter is maintained for reference . On 6/1/2023 at 4:38 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were 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, it was determined the facility staff failed to provide the required documentation upon transfer to the hospital for two of 34 residents in the survey sample, Residents #15 and #58. The findings include: 1. For Resident #15 (R15), the facility staff failed to provide the care plan goals to the receiving facility on 3/4/2023. A nurse's note dated, 3/4/2023 at 7:22 p.m. documented in part, Patient was transported to (initials of hospital) ER (emergency room) as ordered by (name of doctor) approximately 9:15 this evening. EMS (emergency medical services) provided with face sheet, med (medical) hx (history) and med (medication) list. (Initial of hospital) also called and report given to the charge nurse on duty. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:59 p.m. When asked what paperwork is sent with the resident when they are transferred to the hospital, LPN #4 stated, the care plan, bed hold, medication list, last doctor or nurse practitioner note, any recent laboratory tests or x-ray results. LPN #4 was asked where a nurse documents what was sent, LPN #4 stated in the progress notes. The facility policy, Discharge Planning Policy, documented in part, 6. Information to the Receiving Provider. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information including contact information. c. Advance Directive information. d. All special instructions or precautions for ongoing care, as appropriate. e. Comprehensive care plan goals. f. All other necessary information, including a copy of the residents discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit. 2. For Resident #58 (R58), the facility staff failed to evidence documentation of all required paperwork sent to the receiving facility upon transfer on 4/11/2023. The nurse's note dated 4/11/2023 at 8:23 a.m. documented in part, Order received form (name of nurse practitioner) to send resident to ER for left side weakness and non-verbal and the residents needs can no longer be met in the facility. Resident has been notified that she will be going to the ER and the reasons that she is going, pt (patient) is unable to understand that she is going, bed hold and care plan goals sent with the resident. Resident RP (responsible party) also notified of the above and of all the document that accompanied the resident. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:59 p.m. This is the nurse that wrote the above note. When asked what paperwork is sent with the resident when they are transferred to the hospital, LPN #4 stated, the care plan, bed hold, medication list, last doctor or nurse practitioner note, any recent laboratory tests or x-ray results. LPN #4 was asked where a nurse documents what was sent, LPN #4 stated in the progress notes. The above nurse's note was reviewed with LPN #4. When asked if she documented all the documents sent with the resident, LPN #4 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer to the hospital for one of 34 residents in the survey sample, Resident #15. The findings include: For Resident #15, the facility staff failed to provide a bed hold notice upon transfer to the hospital on 3/4/2023. The nurse's note dated, 3/4/2023 at 7:22 p.m. documented in part, Patient was transported to (initials of hospital) ER (emergency room) as ordered by (name of doctor) approximately 9:15 this evening. EMS (emergency medical services) provided with face sheet, med (medical) hx (history) and med (medication) list. (Initial of hospital) also called and report given to the charge nurse on duty. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:59 p.m. When asked what paperwork is sent with the resident when they are transferred to the hospital, LPN #4 stated, the care plan, bed hold, medication list, last doctor or nurse practitioner note, any recent laboratory tests or x-ray results. LPN #4 was asked where a nurse documents what was sent, LPN #4 stated in the progress notes. The facility policy, Bed Hold Letter Policy, documented in part, Business Office or designee will complete the Medicaid Bed Hold Letter and send to the appropriate parties' certified/return receipt requested. The Medicaid Bed Hold Letter can be given directly to the responsible party if they are present. Medicaid Copy will be retained in resident's financial file. This policy provided did not address sending a bed hold notice with a resident upon transfer to the hospital. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined the facility staff failed to accurately complete two MDS (minimum data set) assessments for one of 34 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24), the facility staff failed to accurately code the resident's cognition on two MDS assessment. The admission MDS assessment, with an assessment reference date (ARD) of 1/30/2023 in Section B - Hearing Speech and Vision, coded the resident as being rarely/never understood by others and rarely/never understands when spoken to. In Section C - Cognitive Patterns, R24 was documented, Should Brief Interview for Mental Status be conducted? A 1 was documented indicating the interview should be conducted. A 0 would indicate the resident is rarely/never understood - skip to staff assessment for mental status. The Resident interview was conducted, and the resident scored a 00 out of 15, indicating the resident was severely cognitively impaired for making daily decisions. The staff assessment for mental status was not completed. The quarterly MDS assessment, with an ARD of 5/2/2023 in Section B - Hearing Speech and Vision, coded the resident as being rarely/never understood by others and rarely/never understands when spoken to. In Section C - Cognitive Patterns, R24 was documented, Should Brief Interview for Mental Status be conducted? A 1 was documented indicating the interview should be conducted. A 0 would indicate the resident is rarely/never understood - skip to staff assessment for mental status. The Resident interview was conducted, and the resident scored a 00 out of 15, indicating the resident is severely cognitively impaired for making daily decisions. The staff assessment for mental status was not completed. An interview was conducted with RN (registered nurse) #1 on 6/1/2023 at 1:08 p.m. When asked who completes Sections B and C of the MDS, RN #1 stated she completes Section B and the social worker completes Section C. The above MDS assessments were shared with RN #1. RN#1 stated according to the RAI (resident assessment instrument) manual, if a resident is coded as rarely/never under understood, the staff assessment should be completed. RN #1 was asked if the above MDS assessments were coded correctly, RN #1 stated, no. An interview was conducted with OSM (other staff member) #6, the social worker, on 6/1/2023 at 1:16 p.m. When asked if R24 can be understood and can she understand, OSM #6 stated she sometimes speaks but not very often. Hi is about all they say, not much more than that. The above MDS assessments were reviewed with OSM #6. OSM #6 was asked if Section C - Cognitive Patterns is coded accurately, OSM #6 stated, no. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 20192, documented in part, Determine if the resident is rarely/never understood verbally, in writing, or using another method. If rarely/never understood, skip to C0700-C1000, Staff Assessment of Mental Status. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. 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 promote a residents ability to communicate independently for one of 34 residents, Resident #56. The findings include: The facility staff failed to provide services to promote independent communication with facility staff for Resident #56 (R56), whose primary language spoken was Hungarian. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/13/2023, 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. Section B documented R56 having moderate difficulty with hearing and wearing hearing aids. It also documented R56 having impaired vision, wearing corrective lenses and able to see large print but not regular print. Section F documented having books, newspapers and magazines to read and participating in religious services or practices somewhat important to them. It documented a resident representative completing the assessment for the resident. On 5/31/2023 at 1:02 p.m., R56 was observed sitting in a wheelchair in their room listening to the radio. At that time an interview was attempted with R56. R56 stated, No English. R56 proceeded to pick up their cell phone and attempted to make a call with no answer. No communication tools were observed in R56's room. On 5/31/2023 at 2:28 p.m., an interview was conducted with R56's granddaughter who was visiting in the room. When asked how the staff communicated with R56, she stated that they were unsure. R56's granddaughter stated that R56 knew a few words, could point to things and staff would call them as needed. R56's granddaughter stated that they were not aware of any type of communication tools that the facility staff used. The comprehensive care plan for R56 documented in part, Inability to express emotion, listen and share information. Alteration in communication related to: hearing deficit, Language barrier, blindness. Date Initiated: 03/08/2023. Created on: 02/15/2023. Under Interventions it documented in part, .Teach resident how to use communication book/ board/ electronic device. Date Initiated: 03/08/2023. Created on: 02/15/2023 . The care plan further documented, Resident has a variety of leisure interests but prefers to participate in self-directed leisure. Date Initiated: 03/08/2023. Created on: 02/15/2023. Under Interventions it documented in part, Resident will be given leisure supplies in Hungarian due to language barrier. Date Initiated: 03/08/2023. Created on: 02/15/2023 . The progress notes for R56 documented in part, - 2/15/2023 19:31 (7:31 p.m.) Note Text : IDT (interdisciplinary) team notified by family member of resident's hard of hearing, blindness and language barrier. Resident speaks Hungarian. Assistive devices in use: Resident's has hearing aides. Communication board offered to resident- resident's son requests that facility calls him for interpretation. Son visits everyday- requests that son's number is placed by bedside wall. - 2/26/2023 10:55 (10:55 a.m.) Nursing note .residents' primary language is not English, daughter was able to help resident communicate needs during shift . - 3/19/2023 12:22 (12:22 p.m.) Nursing note .Resident is alert and oriented x 4 (person, place, time and situation) but does have difficulty expressing needs due to language barrier. Resident uses body language many times to express needs, which is effective . - 3/23/2023 22:58 (10:58 p.m.) Nursing note .Resident is alert and oriented x 3 (to person, place and time), with language barrier. Resident's primary language is Hungarian. Resident is able to say a few words in English to communicate needs, and uses body language to communicate. Resident's family does provide assistance with translating . - 4/4/2023 18:13 (6:13 p.m.) Nursing note .Some language barriers, but able to make needs known to staff . - 4/6/2023 13:41 (1:41 p.m.) This writer observed that resident began to cry and became very emotional after son stated resident will remain LTC (long term care) due to the increased amount of assistance with ADLs (activities of daily living). Resident stated in native language that she feels lonely and does not have companionship due to language barrier. Son has been coming in to visit resident every day and is communication with nursing staff/SW (social worker). Son has advised to always call him for translation. SS (social services) will assist in finding LCAs, organizations/groups that speak Hungarian/Romanian for resident companionship. Resident and resident's son agrees. On 6/1/2023 at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that there was a language barrier with R56. LPN #1 stated that R56 did not speak fluent English and would point to things or use hand gestures to communicate with staff. LPN #1 stated that they called the resident's son for any communication with the resident. LPN #1 stated that they were not aware of any type of communication board. LPN #1 stated that they pointed to things to communicate with R56 or called the son as needed to communicate with them. On 6/2/2023 at 8:48 a.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that R56 used hand gestures, nodded their head and gives them the thumbs up to communicate. CNA #4 stated that R56 understood limited English and could point to the juice, coffee and water to make decisions. CNA #4 stated R56 did not have a communication board because they could speak but could not speak English. On 6/2/2023 at 8:58 a.m., an interview was conducted with OSM (other staff member) #8, life enrichment. OSM #8 stated that they worked with R56 and provided activities like doing their nails and taking them outside. OSM #8 stated that they had attempted to get them to participate in group activities but they had refused by shaking their head no. OSM #8 stated that they had taken their communication board when they went to visit with R56 but they did not leave it in the room. OSM #8 stated that they had not provided any books or magazines for R56 in Hungarian but that it was a good idea. OSM #8 stated that they thought that perhaps social services was working on setting up a personalized communication board for R56. On 6/2/2023 at 9:05 a.m., an interview was conducted with OSM # 6, the director of social services. OSM #6 stated that they had requested R56's son to set up a communication board and the director of rehab was working with them. OSM #6 stated that they had discussed this about a month ago. OSM #6 stated that they had reached out to a few organizations and were still trying to find churches in the area that may offer volunteers to come to the facility for R56. On 6/2/2023 at 9:17 a.m., an interview was conducted with OSM #5, the director of rehab services. OSM #5 stated that they were not technically working on setting up a communication board for R56. OSM #5 stated that they had spoken to R56's son who stated that they would work with activities to facilitate a communication board. OSM #5 stated that they were told by the former activities director that R56's son did not comply with setting up the communication board. OSM #5 stated that it should be the facilities responsibility to facilitate communication with the resident not the family. On 6/2/2023 at approximately 9:30 a.m., a request was made to ASM (administrative staff member) #3, assistant director of nursing, for evidence of facility interventions regarding the language barrier with R56. On 6/2/2023 at approximately 10:10 a.m., ASM #2, the director of nursing provided the progress note dated 2/15/2023 documented above. On 6/2/2023 at approximately 11:00 a.m., a follow up interview was conducted with OSM # 6, the director of social services. When asked about the progress note provided dated 2/15/2023, OSM #8 stated that R56's son had declined the communication board that they offered on 2/15/23. OSM #6 stated that R56's son did not really state why he declined the communication board other than it would not work. OSM #6 provided the communication board from their desk, a laminated page approximately 8.5 x 11 inches in size with large pictures of ADL tasks with the English words written underneath. OSM #6 stated that R56 was blind and hard of hearing. When asked if R56 was legally blind and could feed themselves, OSM #6 stated, Yes. When asked if R56 would be able to see a communication board, OSM #6 stated, Yes. OSM #6 stated that this conversation was with R56's son when R56 was at the facility for short-term rehabilitation and they had not had any conversations or approached the subject with the son or the resident since the decision had been made to stay at the facility long term. OSM #6 stated that they had not had a care plan meeting since the transition to long term care but it was scheduled this month. The facility policy, Communication with Persons with Limited English Proficiency with a revision date of 4/15/2021 documented in part, [Name of facility] will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits . On 6/2/2023 at 12:42 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services 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, it was determined the facility staff failed to ensure one of 34 residents in the survey sample, received the care and services in accordance with professional standards and the comprehensive care plan for Resident #22. The findings include: For Resident #22 (R22), the facility staff failed to administer a treatment to the resident's feet per the physician order. On the most recent, MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/25/2033, 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. An interview was conducted with R22 on 5/31/2023 at approximately 11:30 a.m. R22 stated the nurses are not doing her treatments to her feet as ordered. The physician orders dated, 4/17/2023, documented, Skin Prep Bilateral Heels qs (every shift) and prn (as needed), every shift for skin integrity. The April 2023 MAR (medication administration record) documented the above order. There were blanks (areas where staff would document were left blank) on the MAR for the day shift on 4/24/2023 and 4/27/2023 and on the evening shift on 4/26/2023. The May 2023 MAR documented the above order. There were blanks on the MAR for the day shift on 5/1/2023, 5/4/2023, 5/6/2023, 5/7/2023, 5/11/2023, 5/20/2023, 5/21/2023, 5/27/2023 and 5/30/2023. There were blanks on the MAR for evening shift on 5/10/2023 and 5/16/2023. There were blanks on the MAR for the night shift on 5/1/2023. The comprehensive care plan dated, 4/7/2023, documented in part, Focus: Impaired skin integrity related to: diabetic foot ulcer to left lateral ulcer. The Interventions documented in part, Wound treatment per protocol and physician orders. An interview was conducted with LPN (licensed practical nurse) #4 on 6/02/2023 at 8:47 a.m. When asked what do the blanks on a TAR mean, LPN #4 stated, It [the treatment] wasn't done. The facility provided a policy, Physician/Provider Orders did not address the administration of treatments as ordered. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 6/2/2023 at 12:40 p.m. 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 respiratory care and services consistent with professional standards of practice for two of 34 residents, Resident #59 and Resident #122. The findings include: 1. For Resident #59 (R59), the facility staff failed to administer oxygen at the prescribed rate. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/20/2023, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section O documented R59 receiving oxygen at the facility. On 5/31/2023 at 12:56 p.m., R59 was observed in bed wearing an oxygen cannula. The oxygen tubing was dated 5/22 and was set at a rate of 2.5 lpm (liters per minute). Additional observations were made of R59 on 5/31/2023 at 4:10 p.m. and 6/1/2023 at 8:48 a.m. wearing the oxygen cannula with the rate at 2.5 lpm. The physician orders for R59 documented in part, Oxygen: via NC (nasal cannula) at 3L (liters) to maintain SPO2>90% (oxygen saturation greater than 90%), SPO2 check Q (every) shift, every shift. Order Date: 05/31/2023. The comprehensive care plan for R59 documented in part, At risk for altered cardiac/resp (respiratory) status related to aortic stenosis, CAD (coronary artery disease), white coat syndrome. Date Initiated: 03/31/2023. Revision on: 04/05/2023 . Under Interventions it documented in part, O2 (oxygen) as ordered . On 6/1/2023 at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that oxygen was checked every day and administered at the rate based on the order. LPN #1 stated that the flowmeter ball should be centered on the line for the number of the ordered rate. LPN #1 stated that when they checked the rate of the oxygen they read it at eye level. LPN #1 observed R59's oxygen and stated that it was set at 2 lpm. LPN #1 reviewed the order for R59's oxygen and stated that it was ordered at 3 lpm and someone must have set it wrong. The facility policy, Oxygen Administration with a revision date of 12/16/2019 documented in part, .For oxygen concentrator, plug in power cord, turn unit on and set flow meter to correct flow rate . The facility provided manufacturers users manual for R59's oxygen concentrator documented in part, .Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate . On 6/1/2023 at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit. 2. For Resident #122 (R122), the facility staff failed to store a nebulizer mouthpiece in a sanitary manner. On 5/31/2023 at approximately 11:45 a.m. R122 room was observed. There was a nebulizer machine on the nightstand. The mouthpiece used for the administration of medication was open to air. Further observations were made on 5/31/2023 at 2:55 a.m. and 6/1/2023 at 8:12 a.m. and the mouth piece was exposed to air, not covered. On 6/1/2023 at 12:42 p.m. the nebulizer mouthpiece was observed to be exposed to air again and this observation was shared with LPN (licensed practical nurse) #5 at the time. When asked how a nebulizer mouthpiece should be stored when not in use, LPN #5 stated, It should be rinsed after use and stored in a plastic bag. The physician order dated, 5/21/2023, documented, Ipratropium-Albuterol Solution [1] 0.5 - 3.5 (3) MG/3ML (milligrams per 3 milliliter), 3 ml inhale orally every 6 hours related to Chronic Obstructive Pulmonary Disease. The MAR (medication administration record) for May 2023 documented the above order. It was documented that the medication had been administered on 5/31/2023 at 12:00 a.m., 6:00 a.m., and 6:00 p.m. The June 2023 MAR documented the above order. It was documented the resident refused their treatments on 6/1/2023 at 12:00 a.m., 6:00 a.m. and 12:00 p.m. doses of the medication. The facility policy, Nebulizer Administration Policy documented in part, 15. Empty nebulizer cup, rinse with sterile water/sterile saline and air dry. Wipe mask with alcohol wipe and store the neb set in a plastic bag labeled with the patient's name when dried. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit. [1] Ipratropium-Albuterol Solution is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601063.html.

**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 on-call physician availability 24 hours per day for one of 34 residents, Resident #65. The findings include: For Resident #65, the facility staff failed to ensure the on-call physician responded to an emergency situation phone call on [DATE]. Resident #65 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CVA (cerebral vascular accident), CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), CKD (chronic kidney disease), DM (diabetes mellitus), Cirrhosis of Liver and acute and chronic respiratory failure with hypoxia. A review of the comprehensive care plan dated [DATE], which revealed, FOCUS: At risk for altered cardiac /respiratory status. anemia, CAD (coronary artery disease), hyperlipidemia, pulmonary HTN (hypertension), COPD, with acute and chronic respiratory failure with hypoxia, pleural effusion, patent foramen ovale and GERD (gastro-esophageal reflux disease). INTERVENTIONS: 02 as ordered. Monitor for signs/symptoms of decreased cardiac output, rapid, slow, weak or diminished pulse, hypo/hypertension, dizziness, syncope, dyspnea, chest pain, fatigue, restlessness, cyanosis, altered mental status, congestion and shortness of breath. Notify physician as needed with any changes. A review of the nursing progress note, dated [DATE] at 8:03 AM included, Note Text: Resident was seen lethargy, with an oxygen level of 70% at room air during change of shift. resident was repositioned and 15 liter oxygen was administer via non-rebreather mask. resident O@ [sic] went up to 97 % and resident was responsive and having conversion with staff. resident called her full name and was able to identify where she was. O2 level was reduced to 10 liter via non-rebreather mask after resident became stable, alert and oriented X4 and verbally responsive. resident was being monitored every 1 hr. resident retained an oxygen level of 94 to 97% on a simple mask with o2 at 8Lmp. at 0400 resident verbalized abdominal pain and was given hydromorphone 2mg which was effective. at this time, writer called (physician hospital group) on-called [sic] and was awaiting a call back to discuss resident's condition with the DR. but to no avail. at 5 am, resident was stable and resting in bed with an O2 level of 94% via simple mask. at 0540, resident was seen unresponsive. there was no pulse or respiration noted. Writer began CPR and another nurse called 911. 911 arrived at about 0559 and began high pressure CPR. resident could not be resuscitated and was pronounce [sic] dead at about 0626. Resident is he [sic] own responsible party . An interview was conducted on [DATE] at 8:32 AM with LPN (licensed practical nurse) #3. When asked to describe the physician coverage, LPN #3 stated, If it is 7:00 AM-7:00 PM a NP (nurse practitioner) or physician is usually on site. 7:00 PM-7:00 AM, we have to go through the hospital and have the on-call physician paged. We have been having some difficulty and our director of nursing said to start documenting when they do not call back. An interview was conducted on [DATE] at 8:55 AM, with RN (registered nurse) #3. When asked to describe physician coverage, RN #3 stated, On day shift we call their phone and they are available. There is an on-call physician for nights, I have never had to use them. An interview was conducted on [DATE] at 9:05 AM, with LPN #4. When asked to describe physician coverage, LPN #4 stated, We call the physician and if no response or the condition worsens, then we immediately call 911. When asked how frequently the on-call physicians do not respond, LPN #4 stated, It is better recently. It used to happen frequently at nights and then we would send the resident out by 911. An interview was conducted on [DATE] at 9:10 AM with ASM (administrative staff member) #4, the nurse practitioner (NP). When asked to describe the physician/NP notification process, ASM #4 stated, The staff have our phone numbers to call us till 7:00 PM. After 7:00 PM, they call the on-call physician at the hospital. We did not receive notification to my knowledge on this resident. An interview was conducted on [DATE] at 9:49 AM with RN (registered nurse) #2, who was the nurse on duty at the time of the event. When asked to describe the events of [DATE]-[DATE] with Resident #65, RN #2 stated, I got there late, between 11:30 PM-12:00 AM on [DATE]. I made my rounds and the resident was laying across the bed. Her oxygen (O2) was not on. She was lethargic. Her vital signs were normal and O2 saturation was low about 77-78%. I increased her to 15 LNC (liters nasal cannula), got her situated and her O2 saturation came up to 92-93%. Then she was alert and oriented. RN #2 stated, I kept monitoring her oxygen and trying to decrease it. I could not get it back to 4 LNC because her saturation would drop. I had her on a rebreather and finally got her down to 8 liters. I told her that I have to send her to the hospital. She did not want to go. She started having stomach pain, so I gave her narcotic for the pain. RN #2 stated, At 4:00 AM, I called the hospital doctor exchange. I did not get a call back. I called the DON (director of nursing) to let her know of the situation. Resident was reassessed with O2 saturation in 90's on the 8 L face mask. About 5:00 AM, I called the hospital doctor exchange again, talked to resident, and said I have to send you out but the Resident refused to go. RN #2 added, I was the only nurse on the unit, with one CNA .around 5:40 AM, I went to check on (Resident #65) and she was unresponsive. I put her on the floor and started CPR (cardiopulmonary resuscitation). When asked if there were orders to adjust the oxygen, RN #2 stated, No, there was no order. We have standing orders, but they do not cover higher oxygen. I could not keep her on that low oxygen rate. That's the reason I called the physician exchange and the DON. The resident was stable on the higher oxygen, she was not critical at the time, so I did not call 911. I did my due diligence and got her oxygen saturation back up by increasing her oxygen level. An interview was conducted on [DATE] at 11:10 AM with ASM #7, the medical director. When asked to describe the physician notification process, ASM #7 stated, The staff have our cell phones. The physicians are one week on and one week off. There is a NP at facility. After 7:00 PM, staff call the hospital exchange, to reach the physician on call. Response time goes to operator and pages the hospitalist very quickly with a response time of usually 15-30 minutes. There have been instances of on-call physicians not responding, but not recently, for about the last two months. On [DATE] at approximately 11:35 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services was made aware of the findings. An interview was conducted on [DATE] at 11:37 AM, with ASM #2, the director of nursing, who stated, We have had problems with reaching the physician on call, not all the time. It has happened, not sure how frequent. If the staff call me, I tell them to send the resident out if the physician has not responded. An interview was conducted on [DATE] at 11:40 AM, with ASM #1, the administrator, who stated, We have notified the person in charge of the on-call physicians, who is the manager of the physician group. It has gotten better since that conversation. A request for a list of residents with a significant change in condition, list of residents who have expired, and a list of residents who were transferred to the hospital from [DATE] to [DATE] had been requested and received. Residents #58, #60 and #272 were assessed to confirm physicians were notified of a significant change in condition. Two residents, Residents #58 and #60 were transferred to the hospital and returned to the facility with no concerns regarding care they were provided. Resident #272 was placed in hospice and expired in the facility. No pattern of failure to provide physician services 24 hours per day was found. Evidence of any conversation, data related to on-call physician response time was requested. On [DATE] at 12:40 PM, the surveyor was informed there was no further information. A review of the facility's Physician Coverage policy, dated 11/2020, revealed, The community will ensure that residents have access to physician services, including coverage in the event the primary physician/provider is unavailable. Nurse Practitioners and Physician Assistants, where allowed by licensing law and scope of practice, may serve as back-up providers to attending physicians. Physicians/providers will maintain a visit schedule in accordance with state and federal guidelines. Each attending physician/provider will be responsible for notifying the facility of who their covering provider is and how to contact them in the event they will be unavailable due to vacation, illness, etc. In the event that the attending physician/provider or their covering physician/provider cannot be reached then the facility should contact its Medical Director. In the event that the Medical Director is not available or unreachable and no other facility credentialed physician/provider can be reached, the facility should utilize emergency services and local hospital/emergency room physicians. No further information was provided prior to exit.

Based on resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that medications were available for administration for one of 34 residents in the survey sample, Residents #18. The findings include: For Resident #18 (R18), on 12 occasions in March and April 2023, the facility staff failed to administer physician ordered medications. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. On 5/31/2023 at 12:07 p.m., an interview was conducted with R18 in their room. R18 stated that the nurse's frequently ran out of their medications. R18 stated that they kept track of the medications that they took and how many so they noticed if there was less than the normal amount in the cup when they brought it in the room and questioned the nurses. R18 stated that it happened with multiple medications including their Parkinson's medications, vitamins, supplements and heartburn medication. R18 stated that the nurses told them that they were out of the medication or they could not find it. A review of R18's clinical record revealed the following physician's orders: - Pantoprazole Sodium (1) Tablet Delayed Release 40 MG (milligram) Give 1 tablet by mouth two times a day for gerd (gastroesophageal reflux disease). Order Date: 01/08/2023. - Calcitonin (Salmon) Nasal (2) Solution 200 UNIT/ACT (Calcitonin (Salmon)) 1 spray Alternating nostrils one time a day for compression fracture alternate nostrils daily. Order Date: 02/06/2023. - Nitrofurantoin Macrocrystal (3) Capsule 50 MG Give 2 capsule by mouth at bedtime for Chronic UTI (urinary tract infection) Suppression. Order Date: 02/23/2023. - Ocuvite-Lutein Tablet (4) (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. Order Date: 01/08/2023. - Ropinirole HCl ER (extended release) Tablet (5) Extended Release 24 Hour 12 MG Give 1 tablet by mouth at bedtime for restless leg syndrome. Order Date: 01/08/2023. A review of R18's March 2023 eMAR (electronic medication administration record) failed to reveal evidence that Ocuvite-Lutein was administered on 3/28/2023 at 9:00 a.m., Ropinirole 12 mg on 3/9/2023 at 9:00 p.m., Nitrofurantoin 50 mg on 3/22/2023 at 9:00 p.m., and Calcitonin nasal solution on 3/6-3/8/2023 at 9:00 a.m., 3/13-3/15/2023 at 9:00 a.m. and 3/22/2023 at 9:00 a.m. A review of R18's April 2023 eMAR failed to reveal evidence that Pantoprazole 40 mg was administered on 4/26/2023 at 8:00 a.m. and 4/28/2023 at 8:00 a.m. Review of the eMAR notes for R18 documented the medications as not available or on order from the pharmacy for the medications list above. On 6/1/2023 at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident's medication was not available they checked the extra storage on the medication cart and medication room. LPN #1 stated that if the medication was not available in house they contacted the pharmacy to deliver the medication stat. LPN #1 stated that if they were unable to get the medication delivered stat, they contacted the physician for an alternate order or hold order. LPN #1 stated that if the resident was out of the medication the nurse should call the physician to notify them that the dosage was missed and document in the eMAR notes. The facility policy Medication Shortages/Unavailable Medications with a revision date of 1/1/2022 documented in part, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery, if medically necessary .If the medication is unavailable from Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary .When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR or TAR and in the nurse's notes per Facility policy. Such documentation should include the following information: 9.1 A description of the circumstances of the medication shortage; 9.2 A description of Pharmacy's response upon notification; and 9.3 Action(s) taken. On 6/1/2023 at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were made aware of the above concern. Reference: (1) Pantoprazole is used to treat damage from gastroesophageal reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus (the tube between the throat and stomach) in adults and children 5 years of age and older. Pantoprazole is used to allow the esophagus to heal and prevent further damage to the esophagus in adults with GERD. This information was obtained from the website: Pantoprazole: MedlinePlus Drug Information (2) Calcitonin salmon is used to treat osteoporosis in women who are at least 5 years past menopause and cannot or do not want to take estrogen products. Osteoporosis is a disease that causes bones to weaken and break more easily. Calcitonin is a human hormone that is also found in salmon. It works by preventing bone breakdown and increasing bone density (thickness). This information was obtained from the website: Calcitonin Salmon Nasal Spray: MedlinePlus Drug Information (3) Nitrofurantoin is used to treat urinary tract infections. Nitrofurantoin is in a class of medications called antibiotics. It works by killing bacteria that cause infection. Antibiotics such as nitrofurantoin will not work for colds, flu, or other viral infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment. This information was obtained from the website: Nitrofurantoin: MedlinePlus Drug Information (4) Uses of Ocuvite: It is used to help growth and good health. It may be given to you for other reasons. Talk with the doctor. This information was obtained from the website: Ocuvite: Indications, Side Effects, Warnings - Drugs.com (5) Ropinirole is used alone or with other medications to treat the symptoms of Parkinson's disease (PD; a disorder of the nervous system that causes difficulties with movement, muscle control, and balance), including shaking of parts of the body, stiffness, slowed movements, and problems with balance. Ropinirole is also used to treat restless legs syndrome (RLS or Ekbom syndrome; a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down). Ropinirole is in a class of medications called dopamine agonists. It works by acting in place of dopamine, a natural substance in the brain that is needed to control movement. This information was obtained from the website: Ropinirole: MedlinePlus Drug Information

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed ensure two of five residents, reviewed for immunization status, had evidence of pneumococcal immunizations in the clinical record, Residents #35 and #58. The findings include: 1. The facility staff failed to evidence documentation in the clinical record of a pneumococcal immunization for Resident #35 (R35). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/4/2023, the resident was coded in Section O - Special Treatments, Procedures and Program, as not having received the pneumococcal immunization and coded as not having been offered. On 6/2/2023 at 9:51 a.m. ASM (administrative staff member) #3, the assistant director of nursing/infection preventionist, presented documentation of Resident #35's pneumococcal immunization they received on 10/15/2020. When asked where the documentation came from, ASM #3 stated it came from an outside source and was not in the clinical record. The facility policy, Resident Vaccination Policy, documented in part, Residents and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. Influenza, pneumococcal, and COVID vaccination will be offered to all residents and administered per provider orders. Any vaccines ordered will be administered within 7 days of order. The date of historical vaccination[s] will be documented in the health record immunization portal on admission and as information becomes available. Vaccination information may be obtained from the resident/responsible party, past medical records, VIIS documentation, etc. If specific historical vaccination information is not known the resident/representative will provide their best estimate of dates of prior vaccinations and where received. The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were made aware of the above concern on 6/2/2023 at 12:40 p.m. No further information was provided prior to exit. 2. The facility staff failed to evidence documentation in the clinical record of a pneumococcal immunization for Resident #58 (R58). On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 5/10/2023, the resident was coded in Section O - Special Treatments, Procedures and Program, as not having received the pneumococcal immunization and coded as not having been offered. On 6/2/2023 at 9:51 a.m., ASM (administrative staff member) #3, the assistant director of nursing/infection preventionist stated she could not find any documentation in the clinical record related to the pneumococcal immunization for Resident #58. The facility policy, Resident Vaccination Policy, documented in part, Residents and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. Influenza, pneumococcal, and COVID vaccination will be offered to all residents and administered per provider orders. Any vaccines ordered will be administered within 7 days of order. The date of historical vaccination[s] will be documented in the health record immunization portal on admission and as information becomes available. Vaccination information may be obtained from the resident/responsible party, past medical records, VIIS documentation, etc. If specific historical vaccination information is not known the resident/representative will provide their best estimate of dates of prior vaccinations and where received. The Infection Preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were made aware of the above concern on 6/2/2023 at 12:40 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #65, the facility staff failed to follow the comprehensive care plan for oxygen administration and physician notification for a change in condition. Resident #65 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), acute and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section O-special procedures coded oxygen as 'yes'. A review of the comprehensive care plan dated [DATE], revealed, FOCUS: At risk for altered cardiac /respiratory status. anemia, CAD (coronary artery disease), hyperlipidemia, pulmonary HTN (hypertension), COPD, with acute and chronic respiratory failure with hypoxia, pleural effusion, patent foramen ovale and GERD (gastro-esophageal reflux disease). INTERVENTIONS: 02 as ordered. Monitor for signs/symptoms of decreased cardiac output, rapid, slow, weak or diminished pulse, hypo/hypertension, dizziness, syncope, dyspnea, chest pain, fatigue, restlessness, cyanosis, altered mental status, congestion and shortness of breath. Notify physician as needed with any changes. A review of the physician's orders dated [DATE], revealed, 4L (liters per minute) continuous oxygen NC (nasal cannula) - check setting every shift and on rounds everyday shift for O2 Saturation. A review of the nursing progress note dated [DATE] at 8:03 AM, revealed, Resident was seen lethargic, with an oxygen level of 70% on room air during change of shift. resident was repositioned and 15-liter oxygen was administer via non-rebreather mask. resident O2 went up to 97 % and resident was responsive and having conversation with staff. resident called her full name and was able to identify where she was. O2 level was reduced to 10 liters via non-rebreather mask after resident became stable, alert and oriented X4 and verbally responsive. resident was being monitored every 1 hr. resident retained an oxygen level of 94% to 97% on a simple mask with O2 at 8L per minute. at 0400 (4:00 AM) resident verbalized abdominal pain and was given hydromorphone 2mg which was effective. at this time, writer called hospital on call physician and was awaiting a call back to discuss resident's condition with the physician. but to no avail. at 5 am, resident was stable and resting in bed with an O2 level of 94% via simple mask. At 0540 (5:40 AM), resident was seen unresponsive. there was no pulse or respiration noted. Writer began CPR and another nurse called 911. 911 arrived at about 0559 and began high pressure CPR. Resident could not be resuscitated and was pronounce dead at about 0626 (6:26 AM). Resident is her own responsible party. An interview was conducted on [DATE] at 8:32 AM, with LPN (licensed practical nurse) #3. When asked to describe what changes in condition would necessitate physician notification, LPN #3 stated, not alert, could not arouse, if affect different, talking complete nonsense, oxygen saturation, bleeding, falls. When asked if the care plan has intervention of oxygen as ordered and resident is ordered 4 (liters nasal cannula), but oxygen is adjusted to 8-15 liters, is the care plan being followed, LPN #3 stated, No, not following care plan in that instance. An interview was conducted on [DATE] at 9:00 AM, with RN (registered nurse) #3. RN #3 concurred that if the resident has oxygen orders for 4 liters via nasal cannula, with care plan intervention identified as oxygen as ordered, and oxygen is adjusted to 8-15 liters, that the care plan was not being followed. On [DATE] at approximately 11:35 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services was made aware of the findings. 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 implement the comprehensive care plan for five of 34 residents, Residents #56, #59, #18, #65, and #22. The findings include: 1. For Resident #56 (R56) the facility staff failed to implement the comprehensive care plan to A) teach the resident how to use communication devices and B) provide leisure supplies in the residents primary language. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], 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. Section B documented R56 having moderate difficulty with hearing and wearing hearing aids. It also documented R56 having impaired vision, wearing corrective lenses and able to see large print but not regular print. Section F documented having books, newspapers and magazines to read and participating in religious services or practices somewhat important to them. It documented a resident representative completing the assessment for the resident. On [DATE] at 1:02 p.m., R56 was observed sitting in a wheelchair in their room listening to the radio. At this time an interview was attempted with R56. R56 stated, No English. R56 proceeded to pick up their cell phone and attempted to make a call with no answer. No communication tools were observed in R56's room. No leisure supplies in the residents primary language were visible in the room. On [DATE] at 2:28 p.m., an interview was conducted with R56's granddaughter who was visiting in the room. When asked how the staff communicated with (R56), they stated that they were unsure. R56's granddaughter stated that R56 knew a few words, could point to things and staff would call them as needed. R56's granddaughter stated that they were not aware of any type of communication tools that the facility staff used. (A) The facility staff failed to implement the care plan to teach the resident how to use communication devices. The comprehensive care plan for R56 documented in part, Inability to express emotion, listen and share information. Alteration in communication related to: hearing deficit, Language barrier, blindness. Date Initiated: [DATE]. Created on: [DATE]. Under Interventions it documented in part, .Teach resident how to use communication book/ board/ electronic device. Date Initiated: [DATE]. Created on: [DATE] . The progress notes for R56 documented in part, - [DATE] 19:31 (7:31 p.m.) Note Text : IDT (interdisciplinary) team notified by family member of resident's hard of hearing, blindness and language barrier. Resident speaks Hungarian. Assistive devices in use: Resident's has hearing aides. Communication board offered to resident- resident's son requests that facility calls him for interpretation. Son visits everyday- requests that son's number is placed by bedside wall. - [DATE] 10:55 (10:55 a.m.) Nursing note .residents' primary language is not English, daughter was able to help resident communicate needs during shift . - [DATE] 12:22 (12:22 p.m.) Nursing note .Resident is alert and oriented x 4 (person, place, time and situation) but does have difficulty expressing needs due to language barrier. Resident uses body language many times to express needs, which is effective . - [DATE] 22:58 (10:58 p.m.) Nursing note .Resident is alert and oriented x 3 (to person, place and time), with language barrier. Resident's primary language is Hungarian. Resident is able to say a few words in English to communicate needs, and uses body language to communicate. Resident's family does provide assistance with translating . - [DATE] 18:13 (6:13 p.m.) Nursing note .Some language barriers, but able to make needs known to staff . - [DATE] 13:41 (1:41 p.m.) This writer observed that resident began to cry and became very emotional after son stated resident will remain LTC (long term care) due to the increased amount of assistance with ADLs (activities of daily living). Resident stated in native language that she feels lonely and does not have companionship due to language barrier. Son has been coming in to visit resident every day and is communication with nursing staff/SW (social worker). Son has advised to always call him for translation. SS (social services) will assist in finding LCAs, organizations/groups that speak Hungarian/Romanian for resident companionship. Resident and resident's son agrees. On [DATE] at 8:52 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that they were not aware of R56 having any communication devices. On [DATE] at 8:48 a.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that R56 used hand gestures, nodded their head and gives them the thumbs up to communicate. CNA #4 stated that R56 understood limited English and could point to the juice, coffee and water to make decisions. CNA #4 stated R56 did not have any communication devices because they could speak but could not speak English. On [DATE] at 8:58 a.m., an interview was conducted with OSM (other staff member) #8, life enrichment. OSM #8 stated that they had taken their communication board when they went to visit with R56 but they did not leave it in the room. OSM #8 stated that they thought that perhaps social services was working on setting up a personalized communication board for R56. On [DATE] at 9:05 a.m., an interview was conducted with OSM # 6, the director of social services. OSM #6 stated that they had requested R56's son to set up a communication board and the director of rehab was working with them. OSM #6 stated that they had discussed this about a month ago. OSM #6 stated that they had reached out to a few organizations and were still trying to find churches in the area that may offer volunteers to come to the facility for R56. On [DATE] at 9:17 a.m., an interview was conducted with OSM #5, the director of rehab services. OSM #5 stated that they were not technically working on setting up a communication board for R56. OSM #5 stated that they had spoken to R56's son who stated that they would work with activities to facilitate a communication board. OSM #5 stated that they were told by the former activities director that R56's son did not comply with setting up the communication board. OSM #5 stated that it was not the families responsibility to facilitate the communication devices that it was the facilities. On [DATE] at approximately 9:30 a.m., a request was made to ASM (administrative staff member) #3, assistant director of nursing, for evidence of facility interventions regarding communication devices attempted with R56. On [DATE] at approximately 10:10 a.m., ASM #2, the director of nursing provided the progress note dated [DATE] documented above. On [DATE] at approximately 11:00 a.m., a follow up interview was conducted with OSM # 6, the director of social services. When asked about the progress note provided dated [DATE], OSM #8 stated that R56's son had declined the communication board that they offered on [DATE]. OSM #6 stated that R56's son did not really state why he declined the communication board other than it would not work. OSM #6 provided the communication board from their desk, a laminated page approximately 8.5 x 11 inches in size with large pictures of ADL tasks with the English words written underneath. OSM #6 stated that R56 was blind and hard of hearing. When asked if R56 was legally blind and could feed themselves, OSM #6 stated, Yes. When asked if R56 would be able to see a communication board, OSM #6 stated, Yes. OSM #6 stated that this conversation was with R56's son when R56 was at the facility for short-term rehabilitation and they had not had any conversations or approached the subject with the son or the resident since the decision had been made to stay at the facility long term. OSM #6 stated that they had not had a care plan meeting since the transition to long term care but it was scheduled this month. (B) The facility staff failed to implement the care plan to provide leisure supplies in Hungarian due to a language barrier. The comprehensive care plan for R56 documented in part, Resident has a variety of leisure interests but prefers to participate in self-directed leisure. Date Initiated: [DATE]. Created on: [DATE]. Under Interventions it documented in part, Resident will be given leisure supplies in Hungarian due to language barrier. Date Initiated: [DATE]. Created on: [DATE] . The progress notes for R56 failed to evidence documentation of leisure supplies provided in R56 primary language. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that R56 did not speak English but knew a few words and could make hand gestures to communicate what they needed. On [DATE] at 8:58 a.m., an interview was conducted with OSM (other staff member) #8, life enrichment. OSM #8 stated that they worked with R56 and provided activities like doing their nails and taking them outside. OSM #8 stated that they had attempted to get them to participate in group activities but they had refused by shaking their head no. OSM #8 stated that they had not provided any books or magazines for R56 in Hungarian but that it was a good idea. OSM #8 stated that they were not aware that the intervention Resident will be given leisure supplies in Hungarian due to language barrier was on the care plan and that the former activities staff member had written it. The facility policy, Comprehensive Care Planning Policy with a revision date of [DATE] documented in part, The facility must develop a comprehensive Person Centered Care Plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments .All staff must be familiar with each resident's Care Plan and all approaches must be implemented . On [DATE] at 12:42 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit. 2. For Resident #59 (R59), the facility staff failed to implement the care plan to administer oxygen at the prescribed rate. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section O documented R59 received oxygen at the facility. On [DATE] at 12:56 p.m., R59 was observed in bed wearing an oxygen cannula. The oxygen was observed to be dated 5/22 and was set at a rate of 2.5 lpm (liters per minute). Additional observations were made of R59 on [DATE] at 4:10 p.m. and [DATE] at 8:48 a.m. wearing the oxygen cannula with the rate at 2.5 lpm. The comprehensive care plan for R59 documented in part, At risk for altered cardiac/resp (respiratory) status related to aortic stenosis, CAD (coronary artery disease), white coat syndrome. Date Initiated: [DATE]. Revision on: [DATE] . Under Interventions it documented in part, O2 (oxygen) as ordered . The physician orders for R59 documented in part, Oxygen: via NC (nasal cannula) at 3L (liters) to maintain SPO2>90% (oxygen saturation greater than 90%), SPO2 check Q (every) shift, every shift. Order Date: [DATE]. On [DATE] at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that oxygen was checked every day and administered at the rate based on the order. LPN #1 stated that the flowmeter ball should be centered on the line for the number of the ordered rate. LPN #1 stated that when they checked the rate of the oxygen they read it at eye level. LPN #1 observed R59's oxygen and stated that it was set at 2 lpm. LPN #1 reviewed the order for R59's oxygen and stated that it was ordered at 3 lpm and someone must have set it wrong. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that if the care plan said to administer oxygen as ordered, then that was what they did to implement the care plan. On [DATE] at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the concern. No further information was provided prior to exit. 3. For Resident #18 (R18), the facility staff failed to implement the care plan to administer medications as ordered in March and April of 2023. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of [DATE], the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. On [DATE] at 12:07 p.m., an interview was conducted with R18 in their room. R18 stated that the nurse's frequently ran out of their medications. R18 stated that they kept track of the medications that they took and how many so they noticed if there was less than the normal amount in the cup when they brought it in the room and questioned the nurses. R18 stated that it happened with multiple medications including their Parkinson's medications, vitamins, supplements and heartburn medication. R18 stated that the nurses told them that they were out of the medication or they could not find it. The comprehensive care plan for R18 documented in part, The resident is on Antibiotic Therapy r/t (related to) UTI suppression. Date Initiated: [DATE]. Revision on: [DATE]. Under Interventions it documented in part, Administer medications as ordered. Date Initiated: [DATE]. Revision on: [DATE] . The care plan further documented, The resident has Parkinson's Disease, restless leg syndrome, and neuropathy related to DM (diabetes mellitus). Date Initiated: [DATE]. Revision on: [DATE]. Under Interventions it documented in part, Give medications as ordered by the physician. Monitor/document side effects and effectiveness. Date Initiated: [DATE] . A review of R18's clinical record revealed the following physician's orders: - Pantoprazole Sodium Tablet Delayed Release 40 MG (milligram) Give 1 tablet by mouth two times a day for gerd (gastroesophageal reflux disease). Order Date: [DATE]. - Calcitonin (Salmon) Nasal Solution 200 UNIT/ACT (Calcitonin (Salmon)) 1 spray Alternating nostrils one time a day for compression fracture alternate nostrils daily. Order Date: [DATE]. - Nitrofurantoin Macrocrystal Capsule 50 MG Give 2 capsule by mouth at bedtime for Chronic UTI (urinary tract infection) Suppression. Order Date: [DATE]. - Ocuvite-Lutein Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. Order Date: [DATE]. - Ropinirole HCl ER (extended release) Tablet Extended Release 24 Hour 12 MG Give 1 tablet by mouth at bedtime for restless leg syndrome. Order Date: [DATE]. - Carbidopa-Levodopa Tablet 25-100 MG Give 2 tablet by mouth three times a day for Parkinson's disease. Order Date: [DATE]. A review of R18's [DATE] eMAR (electronic medication administration record) failed to reveal evidence that Ocuvite-Lutein was administered on [DATE] at 9:00 a.m., Ropinirole 12 mg on [DATE] at 9:00 p.m., Nitrofurantoin 50 mg on [DATE] at 9:00 p.m., and Calcitonin nasal solution on 3/6-[DATE] at 9:00 a.m., 3/13-[DATE] at 9:00 a.m. and [DATE] at 9:00 a.m. A review of R18's [DATE] eMAR failed to reveal evidence that Pantoprazole 40 mg was administered on [DATE] at 8:00 a.m. and [DATE] at 8:00 a.m. The eMAR failed to reveal evidence that Carbidopa-Levodopa tablet 25-100 mg was administered on [DATE] at 9:00 a.m. and 1:00 p.m. A review of the eMAR note dated [DATE] 08:08 (8:08 a.m.) and 15:36 (3:36 p.m.) documented, Med on order will administer once arrived. On [DATE] at 11:35 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident's medication was not available they checked the extra storage on the medication cart and medication room. LPN #1 stated that if the medication was not available in house they contacted the pharmacy to deliver the medication stat. LPN #1 stated that if they were unable to get the medication delivered stat, they contacted the physician for an alternate order or hold order. LPN #1 stated that if the resident was out of the medication the nurse should call the physician to notify them that the dosage was missed and document in the eMAR notes. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. LPN #1 stated that if the care plan said to administer medications as ordered, then that was what they did to implement the care plan. On [DATE] at 4:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were made aware of the above concern. 5. a. For Resident #22, the facility staff failed to implement the comprehensive care plan for communication with the dialysis center. The comprehensive care plan dated, [DATE], documented in part, Focus: Resident receives dialysis treatments 3 times weekly. The Interventions documented in part, Maintain communication with dialysis staff and physician per routine. An interview was conducted with R22 on [DATE] at approximately 11:30 a.m. R22 was getting ready to leave for dialysis. The resident had told the CNA (certified nursing assistant) to get the nurse so they could give them the prescription that was still in the front of the communication book. R22 stated that their dialysis book was missing for a while, and this is the second book they've had since being admitted to the facility. The dialysis book was reviewed. There was no communication sheet for [DATE]. A nurse came and took the prescription from R22. Review of the clinical record failed to evidence documentation of communication with the dialysis center for 16 of 23 days the resident went to dialysis, from [DATE] through [DATE]. And the facility staff failed to check the dialysis book after dialysis on [DATE]. On [DATE] at 2:46 p.m. the above prescription was reviewed. The prescription dated, [DATE], documented, Renvela (1) 800 mg (milligrams) 2 tabs (tablets) q (every) 8 hrs (hours) with meals. A request was made of on [DATE], for the missing dialysis communication sheets. On [DATE] at 12:54 p.m. ASM (administrative staff member) #3, the assistant director of nursing, presented dialysis communication sheets dated [DATE] through [DATE]. When asked where these documents came from, ASM #3 stated she printed them from the electronic record. When asked if these were the ones sent with the resident for dialysis, ASM #3 stated she had just printed these off today. The forms were blank for where the dialysis center would document on the forms. The resident interview above was shared with ASM #3. An interview was conducted with LPN (licensed practical nurse) #4 on [DATE] at 1:58 p.m. When asked the process for when a resident goes to dialysis, LPN #4 stated the nurse should take the resident's vital signs, document in the computer on the dialysis communication form, print the form out and send with the resident. LPN #4 was asked the process for when the resident returns from dialysis, LPN #4 stated the nurse should look at the book to see if the dialysis center filled in their section and see if there is any communication from the dialysis center that needs to be initiated or action taken on. When asked if a prescription in the book needs to have action taken on, LPN #4 stated, absolutely. The above observation of the prescription still in the book from [DATE] and still in the book on [DATE], was shared with LPN #4. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on [DATE] at 12:40 p.m. No further information was provided prior to exit. 4.b For Resident #22 (R22), the facility staff failed to implement the comprehensive care plan for administering treatments per the physician order. The comprehensive care plan dated, [DATE], documented in part, Focus: Impaired skin integrity related to: diabetic foot ulcer to left lateral ulcer. The Interventions documented in part, Wound treatment per protocol and physician orders. The physician orders dated, [DATE], documented, Skin Prep Bilateral Heels qs (every shift) and prn (as needed), every shift for skin integrity. The [DATE] MAR (medication administration record) documented the above order. There were blanks, which indicated the treatment was not performed, on the MAR for the day shift on [DATE] and [DATE] and on the evening shift on [DATE]. The [DATE] MAR documented the above order. There were blanks on the MAR for the day shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. There were blanks on the MAR for evening shift on [DATE] and [DATE]. There were blanks on the MAR for the night shift on [DATE]. An interview was conducted with LPN (licensed practical nurse) #4 on [DATE] at 8:47 a.m. When asked what do the blanks on a TAR mean, LPN #4 stated, It wasn't done. On [DATE] at 8:52 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was for them to administer patient care and it showed them what they needed to do for the patient and the goals. LPN #1 stated that the care plan was implemented by them doing what it said for them to do on it. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on [DATE] at 12:40 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 the facility staff failed to maintain ongoing communication with the dialysis center for two of 34 residents in the survey sample, Residents #22 and #35. The findings include: 1. For Resident #22 (R22) the facility staff failed to evidence communication with the dialysis center for 16 of 23 days the resident went to dialysis, from 4/5/2023 through 5/31/2023. And, the facility staff failed to check the dialysis book after dialysis on 5/29/2023. On the most recent, MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/25/2033, 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, the resident was coded as receiving dialysis while a resident at the facility. An interview was conducted with R22 on 5/31/2023 at approximately 11:30 a.m. as R22 was getting ready to leave for dialysis. The resident had told the CNA (certified nursing assistant) to get the nurse so they could give them the prescription that was still in the front of the communication book. R22 stated that their dialysis book was missing for a while, and this is the second book they've had since being admitted to the facility. The dialysis book was reviewed. There was no communication sheet for 5/29/2023. A nurse came and took the prescription from R22. On 5/31/2023 at 2:46 p.m. the above prescription was reviewed. The prescription dated, 5/29/2023, documented, Renvela (1) 800 mg (milligrams) 2 tabs (tablets) q (every) 8 hrs (hours) with meals. A request was made on 6/1/2023, for the missing dialysis communication sheets. On 6/1/2023 at 12:54 p.m. ASM (administrative staff member) #3, the assistant director of nursing, presented dialysis communication sheets dated 4/5/2023 through 5/11/2023. When asked where these documents came from, ASM #3 stated she printed them from the electronic record. When asked if these were the ones sent with the resident for dialysis, ASM #3 stated she had just printed these off today. The forms were blank where the dialysis center would document on the forms. The resident interview above was shared with ASM #3. The comprehensive care plan dated, 4/7/2023, documented in part, Focus: Resident receives dialysis treatments 3 times weekly. The Interventions documented in part, Maintain communication with dialysis staff and physician per routine. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:58 p.m. When asked for the process when a resident goes to dialysis, LPN #4 stated the nurse should take the resident's vital signs, document in the computer on the dialysis communication form, print the form out and send with the resident. LPN #4 was asked the process for when the resident returns from dialysis, LPN #4 stated the nurse should look at the book to see if the dialysis center filled in their section and see if there is any communication from the dialysis center that needs to be initiated or action taken on. When asked if a prescription in the book needs to have action taken on, LPN #4 stated, absolutely. The observation of the prescription that was still in the book from 5/29/2023 and still in the book on 5/31/2023, was shared with LPN #4. The facility policy, Hemodialysis Care Policy documented in part, Pre-dialysis process: Administer/hold medications as ordered by provider. Assess resident's condition and communicate any concerns to dialysis provider. If the resident's stability to go to dialysis is in question, notify the dialysis provider for discussion and/or assessment to ascertain if treatment is advisable. If treatment is deferred, the primary provider will be notified for any further orders. Document assessment in the Dialysis Communication Tool. Assessment includes: Vital signs, Pre-treatment weight (unless performed at dialysis), Medications administered before treatment, Time of last meal, Fluid intake, Any additional alerts or information, Print the Tool and send with resident to dialysis (if off-site), Arrange for packed meal to be sent with resident if they will be gone over a mealtime .Post-dialysis process: Receive report from dialysis provider and/or review Dialysis Communication Tool documentation by dialysis provider. Contact dialysis provider promptly with any questions or concerns. Information post-dialysis will include: Amount of fluid removed, Vital signs, Post-treatment weight (unless to be completed by SNF), Lab draws and/or results, Medications administered during or after treatment, Any new orders, Any additional alerts or information, Monitor fistula/graft/catheter site for bleeding, Monitor vital signs and notify provider if outside of parameters ordered, Monitor for dizziness, Meal and/or fluids consumed at dialysis, For fistulas and grafts, dressings may be removed the evening after treatment. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit. (1) Renvela is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis. This information was obtained from the following website: Sevelamer: MedlinePlus Drug Information. 2. For Resident #35 (R35) the facility staff failed to evidence communication with the dialysis center on 4/21/2023, 5/3/2023 and 5/17/2023. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date of 4/4/2023, the resident scored a 15 out of 15 on the BIMS score, indicating the resident is not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, R35 was coded as receiving dialysis while a resident at the facility. The dialysis communication book was reviewed for April 2023 through May 31, 2023. There was missing communication for 4/21/2023, 5/3/2023 and 5/17/2023. A request was made on 6/1/2023 for the missing documents. On 6/1/2023 at 3:43 p.m. ASM (administrative staff member) #2, the director of nursing, stated they didn't have the missing documents. An interview was conducted with LPN (licensed practical nurse) #4 on 6/1/2023 at 1:58 p.m. When asked about the process for when a resident goes to dialysis, LPN #4 stated the nurse should take the resident's vital signs, document in the computer on the dialysis communication form, print the form out and send with the resident. LPN #4 was asked the process for when the resident returns from dialysis, LPN #4 stated the nurse should look at the book to see if the dialysis center filled in their section and see if there is any communication from the dialysis center that needs to be initiated or action taken on. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #268, the facility staff failed to evidence complete and accurate documentation for bladder and bowel elimination continence status. Resident #268 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: stroke, and hemiplegia. Resident #268's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an assessment reference date of 8/21/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section H- Bowel and Bladder: coded the resident as always continent for bladder and bowel. A review of the ADL (activities of daily living) record for August 2022 revealed missing bladder and bowel elimination continence status documentation for 2 out of 16 day shifts, 15 out of 17 evening shifts and 11 out of 17 night shifts. A review of the ADL record for September 2022 revealed missing bladder and bowel elimination documentation for 4 out of 23 day shifts, 20 out of 22 evening shifts and 16 out of 22 night shifts. An interview was conducted on 9/1/23 at 1:00 PM with LPN (licensed practical nurse) #2. When asked if she remembered Resident #268, LPN #2 stated, Yes, she .was very non-compliant. There were so many safety concerns and she would change position by immediately standing up and going to the bathroom. She was continent of both bowel and bladder but did not ring her bell for assistance . An interview was conducted on 9/1/23 at 2:15 PM with CNA (certified nursing assistant) #1 who stated the resident was was continent and would go to the bathroom on her own. When asked if the resident being continent should be documented on the ADL record, CNA #1 stated, Yes, it should. When asked what the blanks in documentation meant, CNA #1 stated, Well, since she was continent, it means that the documentation was not complete. On 6/1/23 at approximately 4:40 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the findings. There is no facility policy regarding a complete and accurate medical record. 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 ensure complete and accurate documentation for two of 34 residents, Resident #58 and Resident #268. The findings include: 1. For Resident #58, the facility staff failed to document the removal of a PICC line (1), to include the length of the catheter removed. The physician order dated 5/23/2023, documented, DC (discontinue) PICC line one time only for 1 day. A request was made on 6/1/2023 at 12:06 p.m. for the documentation of the removal of the PICC line. On 6/1/2023 at 1:14 p.m., ASM (administrative staff member) #2, the director of nursing, presented the May 2023 MAR (medication administration record) that documented the above order. The order was signed off as completed by RN (registered nurse) #4. When asked where the documentation of the length of the catheter that was removed was, ASM #2 stated, It should be documented, but I don't see it. An interview was conducted with RN #4 on 6/1/2023 at 2:03 p.m. RN #4 had approached the surveyor to state, I was on my way off shift for the day. I didn't have the resident, but I was the only RN on duty that day. They asked me to take it out. When asked about the process she followed, RN #4 stated I did hand hygiene, talked to the resident, told them to hold their breath and turn their head away from me. I made sure I had the head of the catheter was at the top. RN #4 was asked if she measured the catheter after it was removed, RN #4 stated she looked at the tube itself. RN #4 stated there was nothing in the chart (medical record) to compare it to. RN #4 stated, What I didn't do was put a note in the record. I made sure the family was aware of it being removed. The facility policy, Central Vascular Access Device (CVAD) Removal (Non-Tunneled), documented in part, Documentation in the medical record includes, but is not limited to:32.1 Date and time. 32.2 Reason for removal. 32.3 Length and condition of catheter and tip. 32.4 Site assessment. 32.5 Patient response to procedure. 32.6 Any action taken if catheter was removed due to complication. 32.7 Patient/significant other teaching. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services, were made aware of the above concern on 5/31/2023 at 4:38 p.m. No further information was provided prior to exit. (1) PICC - Peripherally inserted central catheter, is a long-line catheter made of soft silicone or Silastic material that is placed peripherally but delivers medications and solutions centrally. [NAME], [NAME] & [NAME], Fundamental of Nursing, 5th edition, 2007, page 1423.

**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 ensure one of two residents in the survey sample, (Resident #1), received the care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to administer medications for high blood pressure per the physician order for Resident #1. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, history of a stroke, seizure disorder (a sudden, involuntary, and violent contraction of a group of muscles, sometimes with loss of consciousness. May occur in a seizure disorder or after head trauma.)(1), aphasia (inability to speak or express oneself in writing or to comprehend spoken or written language because of a brain disorder.)(2), and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(3). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 11/17/2021, coded the resident as scoring a 1 on the BIMS (brief interview for mental status) score, indicating the resident was not capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. The physician order dated, 12/30/2021, documented, Hydralazine (used to treat high blood pressure) (4) tablet give 1 tablet by mouth every 24 hours as needed for HTN (high blood pressure). give 1 tab (tablet) (50 mg [milligram]) PO (by mouth) daily for SBP (systolic blood pressure) 180 or greater - check B/P (blood pressure) TID (three times a day) administer per parameter when needed q (every) day. Hydralazine 100 mg, give 100 mg by mouth three times a day for hypertension (high blood pressure). The January 2022 MAR (medication administration record) documented the above order. On 1/5/2022 at 9:00 a.m. the BP (blood pressure) was documented as, 197/91. The 50 mg as needed Hydralazine was not administered at that time as ordered for a systolic blood pressure of 180 or greater. Documentation on the MAR revealed that only the scheduled dose of Hydralazine was administered at 9:00 a.m. The comprehensive care plan dated, 11/17/2021, documented in part, Focus: At risk for altered cardiac/resp (respiratory) status R/T (related to) Dx (diagnosis) HTN, HX (history) of CVA (cerebral vascular accident - stroke) with residual effects. The Interventions documented in part, meds/labs (medications/laboratory tests) as ordered. VS (vital signs - BP, temperature and pulse) as ordered and PRN, notify MD (medical doctor) of any abnormalities. The nurse who was on duty that morning was not available for interview. An interview was conducted with ASM (administrative staff member) #2, the acting director of nursing, on 1/12/2022 at 11:30 a.m. The two orders for Hydralazine were reviewed with ASM #2. When asked if the blood pressure was above the parameters set by the physician, should the PRN (as needed) Hydralazine be given, ASM #2 stated, If the blood pressure was above the parameters, the PRN should have been given in addition to the already scheduled dose. A policy on following physician orders was requested at this time. ASM #1, the administrator, was made aware of the above concern on 1/12/2022 at 12:00 p.m. On 1/12/2022 at approximately 12:30 p.m., ASM #3, the clinical quality specialist, stated the facility did not have a policy on following physician orders. A policy on medication administration was provided. The facility policy, General Dose Preparation and Medication Administration documented in part, Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident if necessary, obtain vital signs .Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight [sic] on appropriate forms. In Fundamentals of Nursing 6th edition, 2005; [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients. 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 141. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 44. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682246.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, family interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of two residents in the survey sample, Resident #1. The facility staff failed to document the education provided to the responsible party regarding the influenza immunization. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, history of a stroke, seizure disorder (a sudden, involuntary, and violent contraction of a group of muscles, sometimes with loss of consciousness. May occur in a seizure disorder or after head trauma.)(1), aphasia (inability to speak or express oneself in writing or to comprehend spoken or written language because of a brain disorder)(2), and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(3). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 11/17/2021, coded the resident as scoring a 1 on the BIMS (brief interview for mental status) score, indicating the resident was not capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. The clinical record documented the administration of the influenza vaccination on 11/17/2021. The record documented the consent was obtained on 11/17/2021. The box next to, Education provided to resident/family was blank. An interview was conducted with ASM (administrative staff member) #3, the clinical quality specialist, on 1/12/2022 at 11:41 a.m. When asked if the education provided to a responsible party related to influenza vaccines be documented in the clinical record, ASM #3 stated it is documented in the immunization tab in the computer. The above documentation was reviewed with ASM #3. A copy of the policy on a complete and accurate clinical record was requested at this time. An interview was conducted with Resident #1's responsible party on 1/12/2022 at 12:41 p.m. The responsible party stated that she had received the education on the influenza vaccine on the day (Resident #1) was admitted to the facility. ASM #1, the administrator, was made aware of the above concern on 1/12/2022 at 2:14 p.m. On 1/12/2022 at 2:16 p.m., ASM #3 stated the facility did not have a policy on a complete and accurate clinical record. A copy of the immunization policy was requested. ASM #3 requested to review the clinical record for documentation of the education for Resident #1 for the influenza vaccination. The facility policy, Resident Vaccination Policy documented in part, The admitting nurse or another licensed clinician/provider will review the CDC (center for disease control) Vaccine Information Statement[s] (VIS) or Emergency Use Authorization (EUA) Statement[s] for any recommended vaccines with the resident/resident representative before obtaining consent. The resident/representative will have an opportunity to ask questions. Education will occur before each dose of vaccine in a multi-dose series is administered .Consents/refusals will be documented in the immunization portal in the medical record. On 1/12/2022 at 2:23 p.m., ASM #3 stated there is no documentation in the clinical record of the education for Resident #1's education for the influenza vaccine. 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 141. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 44. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.

Based on staff interview and facility document review, it was determined the facility staff failed to maintain RN (registered nurse) coverage for eight hours a day for every day. The findings include: Review of the as - worked schedules for the past 30 days was conducted. Review of the December schedules revealed, there was no RN coverage on the following days: 12/12/2021 and 12/26/2021. On 12/25/2021, there was only four hours of RN coverage. Review of the January schedules revealed, there was no RN coverage on the following days: 1/2/2022, and 1/8/2022. An interview was conducted with ASM (administrative staff member) #2, the acting director of nursing, on 1/12/2022 at 10:36 a.m. The schedules above were reviewed with ASM #2. ASM #2 stated, Our thought process was that because we didn't have any skilled residents, we didn't need to have the eight hours of RN coverage. A copy of the policy on RN coverage was requested at this time. On 1/12/2022 at 11:10 a.m., ASM #2 stated the facility did not have a policy on RN coverage. On 1/12/2022 at 12:00 p.m., ASM #1, the administrator, was made aware of the above concern. No further information was provided prior to exit.