**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility staff failed to treat a resident with dignity for one of 29 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to provide feeding assistance in a dignified manner at breakfast on 3/18/25. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/13/24, R1 was coded as being severely impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). She was coded as requiring supervision or touching assistance for eating. On 3/18/25 at 8:44 a.m., R1 was observed sitting up in chair in the day room. She was being fed breakfast by OSM (other staff member) #5, the business office manager. OSM #5 was observed standing beside and over R1 as she fed the resident. On 3/19/24 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated when she feeds or partially assists a resident with eating, she sits down beside the resident. She stated: I like to have eye contact. Standing on top of someone is not good. It is [NAME] important to face them and have eye contact with them. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Assistance with Meals, revealed, in part: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required physician documentation after a resident is transferred to the hospital for one of 29 residents in the survey sample, R24. The findings include: The facility staff failed to evidence required physician documentation after a resident is transferred to the hospital for R24. R24 was transferred to the hospital on [DATE]. R24 was admitted to the facility on [DATE] with diagnosis that included but were not limited to TIA (transient ischemic attack), dysphagia and cognitive communication deficit. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/28/25, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/9/24 revealed, FOCUS: Resident has had an actual fall related to Confusion, Gait/balance problems, mild visual impairment, and HTN (hypertension). INTERVENTIONS: Bed lowest position. Re-educate resident on the importance of using call light for assistance and not transferring himself with no assistance. Call light is within reach and encourage the resident to use it for assistance as needed. He needs prompt response to all requests for assistance. A review of the nursing progress note dated 11/29/24 at 4:39 PM revealed, This nurse was contacted by another nurse r/t resident being in the bed. Resident was assessed, but denied any pain at the time, and no signs of external rotation at this time. Resident was assisted back to bed via staff and transfer lift device. Upon getting resident in the bed, he had c/o of R hip pain, while attempting to do VS. Area assessed further and noticed that R hip bone has a bulge, and it could be seen. MD was contacted to have resident sent out to hospital but left message with receptionist. RP was contacted and informed that resident would be sent to the hospital. EMS contacted for resident transfer. Resident left facility approximately 4:00 PM to hospital. Physician notes were dated 11/16/24 and 12/18/24 with no post hospital physician/NP transfer note evidenced. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes after a resident is transferred to the hospital, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to complete an accurate MDS (minimum data set) for one of 29 residents in the survey sample, Resident #51. The findings include: For Resident #51 (R51), the facility staff failed to complete an accurate 12/31/24 MDS. On R51's most recent MDS, an annual assessment with an ARD (assessment reference date) of 12/31/24, the resident was coded as having no cognitive impairment. He was coded as being physically restrained when in a chair or out of bed. Observations of R51 occurred at the following dates and times: 3/17/25 at 1:00 p.m. and 4:40 p.m.; and 3/18/25 at 8:51 a.m. At none of these observations was R51 physically restrained. On 3/17/25 at 1:00 p.m., R51 stated he had never been physically restrained, and had always had free and independent movement in the bed and in a chair. On 3/19/25 at 8:24 a.m., LPN (licensed practical nurse) #6, the MDS coordinator, was interviewed. She stated she had originally coded R51 as being physically restrained because he used a seatbelt when he was out of bed in a wheelchair. She stated she had recently learned that the seatbelt was not considered a restraint because the resident could release the seatbelt independently, and the seatbelt did not restrict his movement in any way. She stated the process to correct the 12/31/24 MDS was underway, but the modified MDS has not yet been submitted. She did not know why the MDS was not yet submitted. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, MDS Correction, revealed, in part: If an error is discovered in a record that has already been accepted by the [Centers for Medicare and Medicaid Services], implement procedures for either Modification or Inactivation of the information in the system within 14 days of the discovery of the error. No additional information was submitted prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to develop a comprehensive care plan for three of 29 residents in the survey sample, Residents #17, #19, and #1. The findings include: 1. For Resident #17 (R17), the facility staff failed to develop a care plan for the resident's dietary needs. On 3/17/25 at 12:48 p.m., R17 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft, nectar thick liquid .moistened white cake with chopped peaches .no straws. At 1:00 p.m., OSM (other staff member) #4, a speech therapist, also observed R17's meal tray. She confirmed that the regular roll and peach cobbler did not conform with a mechanical soft diet. On 3/17/24 at 5:53 p.m., R17 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce. A review of R17's prescribers' orders revealed the following order, dated 9/27/24: Mechanical Soft texture, Nectar liquids consistency, for oropharyngeal dysphasia; high aspiration risk. NO STRAWS. A review of R17's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated care plans are developed so the residents may have a more productive lifestyle, to do as much as possible independently, and to determine those things with which residents need help. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Care Planning - Comprehensive Person-Centered, revealed, in part: A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident .the resident will receive the services and/or items included in the plan of care .Each resident's comprehensive care plan will describe .services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. No additional information was provided prior to exit. 2. For Resident #19 (R19), the facility staff failed to develop a care plan for the resident's dietary needs. On 3/17/25 at 1:09 p.m., R19 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .pureed bread .moistened white cake with chopped peaches. On 3/17/24 at 5:49 p.m., R19 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed) and canned pineapple slices. A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce .choice of soft, canned, chopped fruit. A review of R19's prescribers' orders revealed the following order, dated 5/14/24: Mechanical Soft texture, Regular/Thin consistency [for liquids]. A review of R19's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated care plans are developed so the residents may have a more productive lifestyle, to do as much as possible independently, and to determine those things with which residents need help. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #1 (R1), the facility staff failed to develop a care plan for the resident's dietary needs. On 3/17/24 at 6:00 p.m., R1 was observed sitting in the day room being fed dinner by a OSM (other staff member) #5, the business office manager. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R1's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R1's prescribers' orders revealed the following order, dated 4/30/24: Dysphagia - Advanced texture. A review of R1's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated care plans are developed so the residents may have a more productive lifestyle, to do as much as possible independently, and to determine those things with which residents need help. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of 29 residents, R39. The findings include: The facility staff failed to meet professional standards by clarifying the oxygen order for R39. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/10/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, supplementary oxygen requirement. INTERVENTIONS: Administer oxygen as ordered. Administer medications as ordered. A review of the physician's order dated 2/12/25 revealed, Oxygen 4 liters via NC (specify continuous) DUE TO RESP FAILURE. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Oxygen Therapy @ 2 LM continuous every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. A review of the February and March 2025 MAR (medication administration record), oxygen 2lnc and oxygen 4lnc are both documented as administered. An interview was conducted on 3/18/25 at 8:45 AM with LPN (licensed practical nurse) #1. When asked to review the oxygen rate of R39, LPN #1 stated, it is on 2 liters nasal cannula. When asked to review the orders, LPN #1 stated, there are two conflicting orders for oxygen administration, one for 2 lnc and one for 4 lnc. When asked where oxygen administration would be evidenced, LPN #1 stated on the MAR. When asked to review R39's MAR, LPN #1 stated, oxygen 2lnc and oxygen 4lnc are both documented as administered. When asked what the professional standard of practice would be in this situation, LPN #1 stated, we should have called to clarify the physician's order and not documented that both rates were administered. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Daily Work Assignments policy, revealed, All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 29 residents, R39. The findings include: The facility staff failed to provide respiratory therapy per physician orders for R39. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/10/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, supplementary oxygen requirement. INTERVENTIONS: Administer oxygen as ordered. Administer medications as ordered. A review of the physician's order dated 2/12/25 revealed, Oxygen 4 liters via NC (specify continuous) DUE TO RESP FAILURE. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Oxygen Therapy @ 2 LM continuous every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. A review of the February and March 2025 MAR (medication administration record), oxygen 2lnc and oxygen 4lnc are both documented as administered. An interview was conducted on 3/18/25 at 8:45 AM with LPN (licensed practical nurse) #1. When asked to review the oxygen rate of R39, LPN #1 stated, it is on 2 liters nasal cannula. When asked to review the orders, LPN #1 stated, there are two conflicting orders for oxygen administration, one for 2 lnc and one for 4 lnc. When asked where oxygen administration would be evidenced, LPN #1 stated on the MAR. When asked to review R39's MAR, LPN #1 stated, oxygen 2lnc and oxygen 4lnc are both documented as administered. When asked what the professional standard of practice would be in this situation, LPN #1 stated, we should have called to clarify the physician's order and not documented that both rates were administered. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Oxygen Administration policy, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Turn on the oxygen at the number of liters / minutes as ordered by the physician/practitioner. Report other information in accordance with facility policy and professional standards of practice. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as needed pain medications for one of 29 residents in the survey sample, Resident #58. The findings include: For Resident #58 (R58), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of as needed pain medications on multiple dates in January, February and March of 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/21/2025, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section J documented R58 having almost constant pain and receiving as needed pain medications. Section J further documented not receiving non-medication interventions for pain. On 3/17/25 at 1:06 p.m., an interview was conducted with R58 who stated that they had pain from a gout flare up and from a recent fall at home with a broken hip. R58 stated that the nurses gave them medications when they asked for it. When asked about non-pharmacological interventions prior to medication administration, R58 stated that they were not sure. The physician order's for R58 documented in part, - Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 3 tablet by mouth every 8 hours as needed for pain related to Pain in Unspecified Joint. Order Date: 01/17/2025. - Oxycodone HCl Oral Capsule 5 MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours as needed for moderate pain related to Pain in Unspecified Joint. Order Date: 01/17/2025. The eMAR (electronic medication administration record) dated 1/1/25-1/31/25 documented the Oxycodone administered to R58 a total of 8 times for pain levels ranging from 3-9. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the Oxycodone. The eMAR dated 2/1/25-2/28/25 documented the Oxycodone administered to R58 a total of 4 times for pain levels ranging from 4-5. The eMAR documented the Acetaminophen administered to R58 once for a pain level of 5. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the Oxycodone or Acetaminophen. The eMAR dated 3/1/25-3/31/25 documented the Acetaminophen administered to R58 once for a pain level of 7. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the Acetaminophen. The progress notes for R58 failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of the as needed pain medication documented on the eMARs. On 3/18/25 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that prior to administering as needed pain medications she assessed the resident, asked them the pain level and how long the pain had been going on. LPN #5 stated that she attempted to reposition the resident and offer non-pharmacological interventions first and if that did not work, she administered the pain medication. She stated that the non-pharmacological interventions should be attempted prior to medication administration unless refused and they were documented on the eMAR or in the progress notes. The facility policy Pain Management documented in part, . 9. Various strategies and modalities may be utilized to assist the resident in achieving optimal comfort. Such strategies and modalities may include, but are not limited to: a. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: i. Environmental - adjusting the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning, etc.; ii. Physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, etc.; iii. Exercise - range of motion exercises to prevent muscle stiffness and contractures; iv. Cognitive or Behavioral - relaxation, music, diversions, activities, etc . On 3/18/25 at 4:42 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure the DON (director of nursing) did not serve as a charge nurse for one of 30 days reviewed. The findings include: The facility staff failed to ensure the DON did not serve as a charge nurse on 3/1/25. A review of facility staffing data revealed the resident census was 72 residents on 3/1/25. A daily nursing assignment form dated 3/1/25 revealed ASM (administrative staff member) #2 (the director of nursing) was documented as the nurse working on the west wing. On 3/18/25 at 4:47 p.m., an interview was conducted with ASM #2. ASM #2 stated she worked as a charge nurse on the floor and medication cart on 3/1/25. On 3/19/25 at approximately 12:15 p.m., ASM #1 (the executive director) and ASM #2 were made aware of the above concern. A specific policy regarding this concern was not provided. No further information was presented prior to exit.

2. For Resident #15 (R15), the facility pharmacist failed to perform a medication regimen review in June and December of 2024. The attending physician failed to respond to the pharmacist's recommendations in June, September, and October 2024. A review of R15's clinical record revealed a 4/19/22 order for Protonix (to treat esophageal reflux) 40 mg (milligrams) daily, an 8/4/22 order for Lorazepam (to treat anxiety) 1 mg twice daily, and a 4/25/24 order for Trileptal (to prevent seizures) 150 mg twice daily. Further review of R15's clinical record revealed no evidence of a monthly medication regimen review by the pharmacist in June and December 2024. This review also revealed the following recommendations by the pharmacist: In May and October 2024, the pharmacist recommended a dose reduction of the Protonix to 20 mg twice daily. In September 2024, the pharmacist recommended a dose reduction of the Lorazepam to 0.5 mg in the morning and 1 mg in the evening. The pharmacist also recommended a dose reduction of Trileptal to 75 mg in the morning and 150 mg in the evening. R15's clinical record revealed no evidence that the facility physician considered and responded to these recommendations in a timely manner. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. ASM #2 stated she distributes the documents to the appropriate attending physicians, and the physicians respond to the recommendations. She stated she has not regularly been scanning the physician recommendations into the residents' electronic medical record. She did not identify a process for follow up to make sure the medication regimen reviews are completed as required, or for physician response to the pharmacist's recommendations. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #17 (R17), the facility pharmacist failed to perform a medication regimen review in April and November of 2024. A review of R17's clinical record revealed no evidence of a monthly medication regimen review by the pharmacist in April and November 2024. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. She did not identify a process for follow up to make sure the medication regimen reviews are completed as required. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to complete and/or act upon monthly pharmacy medication regimen reviews for three of 29 residents in the survey sample, Residents #27, #15 and #17. The findings include: 1. For Resident #27 (R27), the facility staff failed to act upon pharmacy recommendations. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/21/24, the resident was documented as taking an antianxiety and an anticonvulsant medication. The physician orders for R27 documented in part, - Depakote Oral Tablet Delayed Release 125 MG (milligram) (Divalproex Sodium) Give 2 tablet by mouth one time a day for anxiety. Order Date: 03/09/2024. - Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day for anxiety. Order Date: 10/11/2022. The comprehensive care plan for R27 documented in part, - Anticonvulsants: the resident is at risk for adverse reactions related to requiring anticonvulsants for treatment of Mood Disorder Stabilization. Date Initiated: 12/27/2024. - Psychoactive Medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic or hypnotic) medications use secondary to diagnoses of: anxiety disorder. Date Initiated: 12/27/2024. The clinical record for R27 failed to evidence documentation of monthly pharmacy medication regimen reviews completed for the past 12 months. On 3/18/25 at 12:48 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the pharmacist did a review of residents medications monthly and gave her a report upon their exit of any immediate concerns. She stated that he sent her an email with all the reviews and recommendations which she printed out and reviewed. She stated that she completed any nursing recommendations and sent any recommendations for the physician to their offices or contacted them for review. She stated that after the physician reviewed the recommendations, she put in any orders for any medication changes as needed. ASM #2 stated that some of the recommendations were not in the medical record. At that time, a request was made to ASM #1, the executive director, ASM #2 and ASM #3, the regional director of clinical services for evidence of monthly medication regimen reviews for R27 with evidence of physician response for any recommendations made. Review of the facility provided pharmacist medication regimen reviews for the past 12 months for R27 revealed the following recommendations: - A recommendation dated 9/29/24 which documented in part, .The resident has been taking Depakote DR 125mg, 2 tablets (250mg) once daily since (3/10/2024) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps Depakote DR 125mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 8/7/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 8/7/24 which was prior to the pharmacy recommendation for the GDR on 9/29/24. - A recommendation dated 12/16/24 which documented in part, .The resident has been taking Lorazepam 0.5mg once daily since (10/12/2022) without a GDR. Could we attempt a dose reduction at this time to perhaps Lorazepam 0.25mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 12/10/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 12/10/24 which was prior to the pharmacy recommendation for the GDR on 12/16/24. The facility policy Medication Regimen Review documented in part, .The Consultant Pharmacist with perform a medication regimen review (MRR) for every resident in the facility. Routine reviews will be done monthly . The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon . The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record . On 3/19/25 at 12:38 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement interventions to prevent unnecessary medication administration for two of 29 residents in the survey sample, Residents #15 and #39. The findings include: 1. For Resident #15 (R15), the facility staff failed to respond to a pharmacist's recommendation to reduce the dose of Protonix (to treat esophageal reflux) and Trileptal (to prevent seizures). A review of R15's clinical record revealed a 4/19/22 order for Protonix (to treat esophageal reflux) 40 mg (milligrams) daily, an 8/4/22 order for Lorazepam (to treat anxiety) 1 mg twice daily, and a 4/25/24 order for Trileptal (to prevent seizures) 150 mg twice daily. In May and October 2024, the pharmacist recommended a dose reduction of the Protonix to 20 mg twice daily. In September 2024, the pharmacist recommended a dose reduction of Trileptal to 75 mg in the morning and 150 mg in the evening. R15's clinical record revealed no evidence that the facility physician considered and responded to these recommendations in a timely manner. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. ASM #2 stated she distributes the documents to the appropriate attending physicians, and the physicians respond to the recommendations. She stated she has not regularly been scanning the physician recommendations into the residents' electronic medical record. She did not identify a process for follow up to make sure the physician responds to the pharmacist's recommendations. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Medication Regimen Review, revealed, in part: Medication regime reviews will be conducted with the intent to ensure that each resident's entire drug/medication regimen will be managed and monitored to achieve the following goals .Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions .The consulting pharmacist will provide a copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review .The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response .If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician .The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it .If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. No additional information was provided prior to exit. 2. The facility staff failed to ensure R39 was free of unnecessary medications by monitoring anticoagulant as ordered. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/11/25 revealed, FOCUS: ANTICOAGULANTS: the resident is at risk for bleeding and bruising related to use of an anticoagulant for diagnosis of history of heart disease. INTERVENTIONS: Observe for s/s of abnormal bleeding or bruising and or black tarry stools and report to MD as indicated. A review of the physician's order dated 2/10/25 revealed, Eliquis Oral Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day for heart health and physician order dated 3/17/25 ANTICOAGULANT MEDICATION - MONITOR FOR DISCOLORED URINE, BLACK TARRY STOOLS, SUDDEN SEVERE HEADACHE, N&V, DIARRHEA, MUSCLE JOINT PAIN, LETHARGY, BRUISING, SUDDEN CHANGES IN MENTAL STATUS AND/ OR V/S, SOB, NOSE BLEEDS. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift -Start Date03/17/2025 2300. R39's MAR (medication administration record) does not evidence any monitoring of anticoagulation monitoring till night shift on 3/17/25 after we entered on day shift 3/17/25. On 3/18/25 at 8:30 AM, an interview was conducted with LPN (licensed practical nurse) #1. When asked what monitoring is provided for anticoagulation, LPN #1 stated, we monitor for bruising, bleeding and blood in the urine or stool. When asked where this would be evidenced, LPN #1 stated, we document this on the MAR. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Medication and Treatment Orders policy, revealed, Orders for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement interventions to prevent unnecessary psychoactive medication administration for two of 29 residents in the survey sample, Residents #15 and #39. The findings include: 1. For Resident #15 (R15), the facility staff failed to respond to a pharmacist's recommendation to reduce the dose of Lorazepam (to treat anxiety). A review of R15's clinical record revealed an 8/4/22 order for Lorazepam (to treat anxiety) 1 mg twice daily. In September 2024, the pharmacist recommended a dose reduction of the Lorazepam to 0.5 mg in the morning and 1 mg in the evening R15's clinical record revealed no evidence that the facility physician considered and responded to this recommendations in a timely manner. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. ASM #2 stated she distributes the documents to the appropriate attending physicians, and the physicians respond to the recommendations. She stated she has not regularly been scanning the physician recommendations into the residents' electronic medical record. She did not identify a process for follow up to make sure the physician responds to the pharmacist's recommendations. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Medication Regimen Review, revealed, in part: Medication regime reviews will be conducted with the intent to ensure that each resident's entire drug/medication regimen will be managed and monitored to achieve the following goals .Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions .The consulting pharmacist will provide a copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review .The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response .If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician .The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it .If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. No additional information was provided prior to exit. 2. For Resident #27 (R27), the facility staff failed to respond to pharmacy recommendations to prevent potential unnecessary psychotropic medications. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/21/24, the resident was documented as taking an antianxiety and an anticonvulsant medication. The physician orders for R27 documented in part, - Depakote Oral Tablet Delayed Release 125 MG (milligram) (Divalproex Sodium) Give 2 tablet by mouth one time a day for anxiety. Order Date: 03/09/2024. - Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day for anxiety. Order Date: 10/11/2022. The comprehensive care plan for R27 documented in part, - Anticonvulsants: the resident is at risk for adverse reactions related to requiring anticonvulsants for treatment of Mood Disorder Stabilization. Date Initiated: 12/27/2024. - Psychoactive Medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic or hypnotic) medications use secondary to diagnoses of: anxiety disorder. Date Initiated: 12/27/2024. The clinical record for R27 failed to evidence documentation of monthly pharmacy medication regimen reviews completed for the past 12 months. On 3/18/25 at 12:48 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the pharmacist did a review of residents monthly and gave her a report upon their exit of any immediate concerns. She stated that he sent her an email with all the reviews and recommendations which she printed out and reviewed. She stated that she completed any nursing recommendations and sent any recommendations for the physician to their offices or contacted them for review. She stated that after the physician reviewed the recommendations, she put in any orders for any medication changes as needed. ASM #2 stated that some of the recommendations were not in the medical record. At that time, a request was made to ASM #1, the executive director, ASM #2 and ASM #3, the regional director of clinical services for evidence of monthly medication regimen reviews for R27 with evidence of physician response for any recommendations made. Review of the facility provided pharmacist medication regimen reviews for R27 documented the following recommendations: - A recommendation dated 9/29/24 which documented in part, .The resident has been taking Depakote DR 125mg, 2 tablets (250mg) once daily since (3/10/2024) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps Depakote DR 125mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 8/7/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 8/7/24 which was prior to the pharmacy recommendation for the GDR on 9/29/24. - A recommendation dated 12/16/24 which documented in part, .The resident has been taking Lorazepam 0.5mg once daily since (10/12/2022) without a GDR. Could we attempt a dose reduction at this time to perhaps Lorazepam 0.25mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 12/10/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 12/10/24 which was prior to the pharmacy recommendation for the GDR on 12/16/24. On 3/19/25 at 12:38 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, clinical record review, staff interview, and facility document review, it was determined the facility staff failed to provide assistive devices during meals for one of 29 residents in the survey sample, Resident #37. The findings include: For Resident #37 (R37), the facility staff failed to provide a divided plate as ordered during meals. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/24, the resident scored three out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were severely impaired for making daily decisions. Section K documented no weight loss or swallowing difficulty. Observation of R37 on 3/17/25 at 1:24 p.m. revealed the resident sitting in bed eating lunch. The lunch was observed to be served with each portion in separate bowls on a tray. On 3/18/25 at 1:14 p.m., an observation of R37's lunch revealed it served on a regular plate. The physician orders for R37 documented in part, Divided/sectional plate at all meals. Order Date: 10/24/2024. The comprehensive care plan for R37 documented in part, Nutritional Status: the resident is at risk for weight loss, malnutrition or poor hydration status related to chronic disease, cognitive impairment, GERD (gastrointestinal reflux disease). Date Initiated: 01/29/2025. The care plan failed to evidence documentation of the use of assistive devices during meals. On 3/18/25 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that they supervised R37 when eating and queued them to eat. She stated that R37 used their hands and fingers to eat a lot. She stated that she did not recall the resident using a divided plate during meals but may had seen one used in the past. On 3/18/25 at 4:13 p.m., an interview was conducted with OSM (other staff member) #4, speech language pathologist. OSM #4 stated that they had not worked with R37 since May of 2024, but they placed the order for the divided plate on 10/24/2024. She stated that it was probably from a recommendation that was made from a routine screening, and she would check her files. On 3/18/25 at approximately 4:35 p.m., OSM #4 provided a handwritten therapy evaluation for R37 dated 10/24/24 which documented recommendations of .Recommend divided/sectional plate at all meals to (decrease) spillage from plate, thereby increasing po (by mouth) intake. The facility policy Assistance with meals documented in part, .Residents will receive assistance with meals in a manner that meets the individual needs of each resident . 2. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 3. Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils . On 3/18/25 at 4:42 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #13 (R13) the facility staff failed to review and revise the care plan with a specialized diet order. On 3/17/25 at 12:55 p.m., R13 was observed sitting up in bed eating lunch. The resident's lunch tray contained regular consistency potato salad and peach cobbler (peach slices and cobbler crust). A review of R13's meal ticket revealed, in part: Dysphagia advanced .peaches and cream cake. On 3/17/24 at 5:55 p.m., R13 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R13's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R13's prescribers' orders revealed the following order, dated 2/11/25: Dysphagia - Advanced texture. A review of R13's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated floor nurses have the ability to update a resident's care plan, but generally the floor nurses tell members of management when care plans need to be updated. The management team usually review and revise the care plans based on nurse input. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #20 (R20), the facility staff failed to review and revise the care plan with a specialized diet order. On 3/17/24 at 5:50 p.m., R20 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R20's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R20's prescribers' orders revealed the following order, dated 10/10/24: Dysphagia - Advanced texture. A review of R20's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated floor nurses have the ability to update a resident's care plan, but generally the floor nurses tell members of management when care plans need to be updated. The management team usually review and revise the care plans based on nurse input. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. Based on observation, clinical record review, staff interview, and facility document review, it was determined the facility staff failed to revise the comprehensive care plan for four of 29 residents in the survey sample, Resident #37, #39, #13, and #20. The findings include: 1. For Resident #37 (R37), the facility staff failed to revise the comprehensive care plan to include the use of a divided plate at meals. Observation of R37 on 3/17/25 at 1:24 p.m. revealed the resident sitting in bed eating lunch. The lunch was observed to be served with each portion in separate bowls on a tray. On 3/18/25 at 1:14 p.m., an observation of R37's lunch revealed it served on a regular plate. The physician orders for R37 documented in part, Divided/sectional plate at all meals. Order Date: 10/24/2024. The comprehensive care plan for R37 documented in part, Nutritional Status: the resident is at risk for weight loss, malnutrition or poor hydration status related to chronic disease, cognitive impairment, GERD (gastrointestinal reflux disease). Date Initiated: 01/29/2025. The comprehensive care plan failed to evidence documentation of the use of assistive devices during meals. On 3/18/25 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that the staff supervised R37 when eating and queued them to eat. She stated that R37 used their hands and fingers to eat a lot. She stated that she did not recall the resident using a divided plate during meals but may had seen one used in the past. She stated that the purpose of the care plan was to show the care that they were to give the patient, and it was a tool to follow. On 3/18/25 at 4:13 p.m., an interview was conducted with OSM (other staff member) #4, speech language pathologist. OSM #4 stated that they had not worked with R37 since May of 2024, but they placed the order for the divided plate on 10/24/2024. She stated that it was probably from a recommendation that was made from a routine screening, and she would check her files. On 3/18/25 at approximately 4:35 p.m., OSM #4 provided a handwritten therapy evaluation for R37 dated 10/24/24 which documented recommendations of .Recommend divided/sectional plate at all meals to (decrease) spillage from plate, thereby increasing po (by mouth) intake. On 3/19/25 at 8:24 a.m., an interview was conducted with LPN #6, the MDS (minimum data set) coordinator. She stated that she reviewed care plans daily for accuracy, and particularly focused on new orders or items contained in the 24-hour report. She stated floor nurses had the ability to update care plans, but generally they did not. She stated that the comprehensive care plan reviews included all orders and interventions a resident required. LPN #6 stated that the divided plate was an intervention that should have been included on R37's care plan and she had updated the care plan on 3/18/24. The facility policy Care Planning-Comprehensive Person Centered documented in part, . Each resident's comprehensive care plan will describe the following: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 13. The comprehensive care plan will: a. Incorporate identified problem areas; b. incorporate risk factors associated with identified problems . e. Reflect treatment goals, timetables and objectives in measurable outcomes . On 3/19/25 at 12:38 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit. 2. The facility failed to revise the comprehensive care plan for oxygen administration for R39. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/10/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, supplementary oxygen requirement. INTERVENTIONS: Administer oxygen as ordered. Administer medications as ordered. Care Plan revised 2/11/25. A review of the physician's order dated 2/12/25 revealed, Oxygen 4 liters via NC (specify continuous) DUE TO RESP FAILURE. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Oxygen Therapy @ 2 LM continuous every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. A review of the February and March 2025 MAR (medication administration record), oxygen 2lnc and oxygen 4lnc are both documented as administered. An interview was conducted on 3/18/25 at 8:45 AM with LPN (licensed practical nurse) #1. When asked to review the oxygen rate of R39, LPN #1 stated, it is on 2 liters nasal cannula. When asked to review the orders, LPN #1 stated, there are two conflicting orders for oxygen administration, one for 2 lnc and one for 4 lnc. When asked where oxygen administration would be evidenced, LPN #1 stated on the MAR. When asked to review R39's MAR, LPN #1 stated, oxygen 2lnc and oxygen 4lnc are both documented as administered. When asked what the professional standard of practice would be in this situation, LPN #1 stated, we should have called to clarify the physician's order and not documented that both rates were administered. When asked if the care plan should have been reviewed and revised with oxygen setting, LPN #1 stated, yes, it should have been reviewed. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Care Planning-Comprehensive Centered policy, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident / staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of the frequency of physician visits at least every 60 days for five of 29 residents in the survey sample, R48, R9, R59, R28 and R56. The findings include: 1. R48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/19/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for mobility/transfers/bathing/dressing and eating. A review of the comprehensive care plan dated 1/7/25 revealed, FOCUS: the resident is a long-term care resident and requires assistance with their ADL's related to chronic health conditions, muscle weakness. INTERVENTIONS: Encourage the resident to participate to the fullest extent possible with each interaction. Supervision or touching assistance with bed mobility and transfers. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 9/25/24, 11/16/24, 2/5/25. A period of 81 days between physician visits on 11/16/24 to 2/5/25. An interview was conducted on 3/17/25 at approximately 2:00 PM with R48. When asked if she had any concerns, R48 asked, can I get another doctor. I do not see this doctor and he does not seem to be doing much for me. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 2. R9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to MS (multiple sclerosis), DM (diabetes mellitus) and respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/16/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 11/15/24 revealed, FOCUS: CARDIAC: the resident is at risk for cardiac complications secondary to hypertension. INTERVENTIONS: observe for signs and symptoms of fluid overload including pulmonary or lower extremity edema and shortness of breath and notify MD as indicated. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 12/11/24, no January 2025, February 2025 or March 2025 physician notes. As of 3/19/25, 98 days since 12/11/24 note. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 3. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to encephalopathy, dysphagia and respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/6/25, coded the resident as scoring a 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/17/24 revealed, FOCUS: ANTICOVULSANTS: the resident is at risk for adverse reactions related to requiring anticonvulsants for treatment of Mood Disorder Stabilization. INTERVENTIONS: Observe for signs and symptoms of convulsive activity and notify MD as indicated. observe for increased sedation, drowsiness, dizziness, and report to MD as indicated. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 11/23/24, 11/27/24 and 2/15/25. No December 2024 or January 2025 physician notes. 80 days between 11/27/24 and 2/15/25 physician notes. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 4. R28 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular infarction), hemiplegia/hemiparesis and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/11/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximum assist for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 1/29/25 revealed, FOCUS: CONVULSIVE DISORDER: The resident has a risk for complications secondary to epilepsy. INTERVENTIONS: Observe for convulsive activity and notify MD as indicated. Administer meds as ordered. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 11/27/24, no additional physician notes from 11/27/24 to 3/19/25 a period of 112 days. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 5. R56 was admitted to the facility on [DATE] with diagnosis that included but were not limited to metabolic encephalopathy, CHF (congestive heart failure) and Alzheimer's. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/25/25, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/15/24 revealed, FOCUS: CARDIAC: the resident is at risk for cardiac complications secondary to congestive heart failure. INTERVENTIONS: observe for signs and symptoms of fluid overload including pulmonary or lower extremity edema and shortness of breath and notify MD as indicated. Administer medications as ordered. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 8/21/24, 11/20/24 and 2/21/25. No additional notes from 8/21/24 to 11/20/24 a period of 91 days and no additional notes from 11/20/24 to 2/21`/25 a period of 93 days. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit.

Based on observation, resident interview, facility staff interview, facility document review, and clinical record review, the facility staff failed to serve food in a form to meet resident needs for five of 29 residents in the survey sample, Residents #17, #19, #13, #1, and #20. The findings include: 1. For Resident #17 (R17), the facility staff failed to serve a mechanical soft diet on 3/17/25 at both the lunch and dinner meals. On 3/17/25 at 12:48 p.m., R17 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). The resident's tray also contained an empty Mountain Dew can with a straw. R17 stated his sister had brought the Mountain Dew earlier in the day and he had consumed the whole can using a straw. He stated the Mountain Dew was not thickened. A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft, nectar thick liquid .moistened white cake with chopped peaches .no straws. At 1:00 p.m., OSM (other staff member) #4, a speech therapist, also observed R17's meal tray. She confirmed that the regular roll and peach cobbler did not conform with a mechanical soft diet. She also confirmed that the resident should not have a can of unthickened Mountain Dew on his overbed table and should not have consumed the Mountain Dew using a straw. On 3/17/24 at 5:53 p.m., R17 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce. A review of R17's prescribers' orders revealed the following order, dated 9/27/24: Mechanical Soft texture, Nectar liquids consistency, for oropharyngeal dysphasia; high aspiration risk. NO STRAWS. A review of R17's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM #4 was interviewed. She stated a resident who has orders for a mechanical soft diet should always receive pureed bread, ground meat (consistency of ground hamburger), soft vegetables, and soft fruit that is chopped. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on a mechanical soft diet should receive ground meat, soft (cooked) vegetables, chopped cold side dishes, mashed potatoes, chopped desserts, pureed bread, and chopped fruit. She stated mechanical soft meat should be the consistency of ground beef. She stated R17's 3/17 lunch potato salad should have been chopped. She stated she did not check the cobbler before it left the kitchen, and the cobbler should have been cut into smaller pieces. She stated R17 should not have been given a regular roll at any time. She stated R17's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Texture and Consistency-Modified Diets, revealed, in part: Texture and consistency-modified diets will be individualized with modifications made by the speech-language pathologist and physician in conjunction with the registered dietician-nutritionist and director of food and nutrition services. A written order is needed .The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered .Diets should be adjusted to meet individual needs. No additional information was provided prior to exit. 2. For Resident #19 (R19), the facility staff failed to serve a mechanical soft diet on 3/17/25 at both the lunch and dinner meals. On 3/17/25 at 1:09 p.m., R19 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .pureed bread .moistened white cake with chopped peaches. On 3/17/24 at 5:49 p.m., R19 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed) and canned pineapple slices. A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce .choice of soft, canned, chopped fruit. A review of R19's prescribers' orders revealed the following order, dated 5/14/24: Mechanical Soft texture, Regular/Thin consistency [for liquids]. A review of R19's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a mechanical soft diet should always receive pureed bread, ground meat (consistency of ground hamburger), soft vegetables, and soft fruit that is chopped. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on a mechanical soft diet should receive ground meat, soft (cooked) vegetables, chopped cold side dishes, mashed potatoes, chopped desserts, pureed bread, and chopped fruit. She stated mechanical soft meat should be the consistency of ground beef. She stated R19's 3/17 lunch potato salad should have been chopped. She stated she did not check the cobbler before it left the kitchen, and the cobbler should have been cut into smaller pieces. She stated R19's dinner meat should have been ground, not cubed, and the resident should have been given crushed or chopped pineapple, not a whole pineapple slice. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #13 (R13), the facility staff failed to serve an advanced dysphagia diet on 3/17/25 at both the lunch and dinner meals. On 3/17/25 at 12:55 p.m., R13 was observed sitting up in bed eating lunch. The resident's lunch tray contained regular consistency potato salad and peach cobbler (peach slices and cobbler crust). A review of R13's meal ticket revealed, in part: Dysphagia advanced .peaches and cream cake. On 3/17/24 at 5:55 p.m., R13 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R13's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R13's prescribers' orders revealed the following order, dated 2/11/25: Dysphagia - Advanced texture. A review of R13's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a dysphagia advanced diet should always receive ground meat, soft vegetables, and soft fruit. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on an advanced dysphagia diet should receive chopped meat. She stated R1's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #1 (R1), the facility staff failed to serve an advanced dysphagia diet on 3/17/25 at dinner. On 3/17/24 at 6:00 p.m., R1 was observed sitting in the day room being fed dinner by a OSM (other staff member) #5, the business office manager. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R1's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R1's prescribers' orders revealed the following order, dated 4/30/24: Dysphagia - Advanced texture. A review of R1's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a dysphagia advanced diet should always receive ground meat, soft vegetables, and soft fruit. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on an advanced dysphagia diet should receive chopped meat. She stated R13's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 5. For Resident #20 (R20), the facility staff failed to serve an advanced dysphagia diet on 3/17/25 at dinner. On 3/17/24 at 5:50 p.m., R20 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R20's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R20's prescribers' orders revealed the following order, dated 10/10/24: Dysphagia - Advanced texture. A review of R20's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a dysphagia advanced diet should always receive ground meat, soft vegetables, and soft fruit. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on an advanced dysphagia diet should receive chopped meat. She stated R20's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The findings include: On 3/17/25 at 10:20 AM, an observation was conducted in the main kitchen. In the refrigerator, there was found one large five-pound bag of shredded sharp cheese that was opened and not dated. OSM (other staff member) #1, the dietary manager was observed with the back of her hair without a hair net covering. An interview was conducted on 3/17/24 at 10:40 AM with OSM (other staff member) #1, the dietary manager. When asked to review the five-pound bag of shredded sharp cheese, OSM #1 stated, that should be dated, we just opened it for breakfast. When asked about the back of her hair not having a covering, OSM #1 stated, there was one on my hair, I do not know where it went. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. The facility's Food Safety and Sanitation policy revealed the following, Food Storage: When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Employees: Are required to have their hair styled so that it does not touch the collar. Hair restraints are required and should cover all hair on the head. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain clean dumpster area during the facility task- kitchen observation 3/17/25 at 10:30 AM. The findings include: On 3/17/25 at 10:30 AM, an observation was conducted in the dumpster area outside of the main kitchen, with OSM (other staff member) #1, the dietary manager. Dumpster #1 had an open seam on the front bottom of the dumpster. Tin foil with food debris and a white paper/trash bag were hanging out of the seam. In front of the dumpster was a half sandwich and citrus peel. Dumpster #2 had a bifold lid. The right side of the bifold lid was open all the way back. An interview was conducted on 3/17/24 at 10:40 AM with OSM #1, the dietary manager. When asked about the findings, OSM #1 stated, they just picked the trash up this morning, and we have not had a chance to come out and clean this area. We communicated with the county about a new trash dumpster last week. When asked who was responsible for the dumpster area, OSM #1 stated, maintenance and dietary. On 3/18/25 at 7:30 AM, ASM (administrative staff member) #1, the executive director stated, we have been calling the county about a new dumpster, and they finally brought a new one this morning. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. The facility's Waste Disposal policy revealed the following, Prior to disposal, all waste shall be kept in leak-proof, non-absorbent containers that are kept covered when not in use. Trash will be deposited into a sealed container outside the premises. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 03/15/2022 at 7:45 a.m., during the initial tour the drywall in the bathroom located in room [ROOM NUMBER] was observed in disrepair. The wall in the bathroom located near the baseboard had a section of drywall that was pushed in and had an uneven surface. On 03/16/2022 at 10:36 a.m., accompanied with the maintenance director (OS #2) in room [ROOM NUMBER], OS #2 was interviewed regarding the bathroom wall being in disrepair. OS #2 stated a couple of weeks earlier he had been made aware of a small area that needed repair in the bathroom; however the area was now larger. OS #2 stated, I think the roommate was ramming his wheelchair against the wall. He tends to do that a lot and that is why I have put the plastic/plexiglass material around the walls of the room. So I guess I will need to do the same for the bathroom. OS #2 was asked if there was a maintenance request system. OS #2 stated, We have a maintenance binder that I review 3 days per week. We also get information from the morning meetings. I don't think there was a maintenance request in the binder. I think I was told about the small area needing repair during the morning meeting. The above findings were reviewed with the administrator, director of nursing (DON), and corporate staff during a meeting on 03/16/2022 at 4:30 p.m. No additional information was provided to the survey team prior to exit on 03/17/2022 at 12:30 p.m. Based on observation, staff interview and clinical record review, the facility staff failed to ensure a wheelchair was clean and in safe condition for one of eighteen residents, Resident #3; and failed to ensure a homelike room environment on one of three units. Resident #3's wheelchair was dirty and with worn/torn cushions. Wall damage was observed in room [ROOM NUMBER]. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included atherosclerotic heart disease, COPD (chronic obstructive pulmonary disease), hypertension, gastroesophageal reflux disease, major depressive disorder, dementia, congestive heart failure and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed Resident #3 with severely impaired cognitive skills. On 3/16/22 at 9:34 a.m., Resident #3 was observed seated in a scoot type wheelchair near the nursing desk. The upper right side of the chair back was torn with foam visible. The left arm cushion was deteriorated. Crumbs, drips and lint were accumulated on the support bars under the seat. The rear of the seat cushion was covered with crumbs and debris. On 3/16/22 at 1:45 p.m., registered nurse (RN) #2 was interviewed about the condition of Resident #3's wheelchair. RN #2 stated the wheelchair seat cushion had a hole where the resident moved back and forth in the seat. RN #2 stated the wheelchairs were supposed to be cleaned on a regular basis. On 3/16/22 at 3:46 p.m., the director of nursing (DON) was interviewed about Resident #3's wheelchair. The DON stated she looked at the chair today and the armrest was worn with metal exposed. The DON stated the seat covering was also cracked from use. The DON stated she removed the chair from use due to safety concerns regarding the exposed metal on the armrest. This finding was reviewed with the administrator and director of nursing during a meeting on 3/16/22 at 4:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and during the course of a complaint investigation, the facility staff failed to develop and implement a baseline care plan for diabetes mellitus (DM) and pressure ulcers, for one of 18 residents in the survey sample, Resident #212. Findings include: Resident #212 was admitted to the facility with diagnoses included, but were not limited to: aftercare of left hip fracture with repair (arthroplasty), CHF (congestive heart failure), reflux, diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, high blood pressure, history of pneumonia, muscle weakness, and history of falls. The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13 indicating the resident was intact for daily decision making skills. Resident #212's clinical records were reviewed. A baseline care could not be found for Resident #212's immediate care for diabetes mellitus and pressure ulcers. On 03/16/22 at approximately 11:00 AM, the MDS coordinators licensed practical nurse (LPN) #2 and registered nurse (RN) #3, were interviewed regarding the baseline care plan for Resident #212 for diabetes and pressure ulcers. LPN #2 stated that the baseline care plans are on initially on paper. LPN #2 was made aware that Resident #212 had discharged from the facility on 11/17/21 and was asked if the initial care plan should have been scanned into the resident's EMR (electronic medical record). LPN #2 stated that it should have been scanned and would check with medical records and look for the baseline care plan for Resident #212. On 03/16/22 at approximately 2:30 PM, LPN #2 and RN #3 stated that a baseline care plan for Resident #212 in the areas of pressure ulcers and diabetes could not be found or had not been completed. No further information was provided prior to exit. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for two of 18 residents in the survey sample, Resident #7 and Resident #212. Resident #7's CCP did not include a focus area with goals and interventions for the use of the antianxiety medication, Buspirone; and Resident #212's CCP did not include a focus areas with goals and interventions for diabetes. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included anemia, cellulitis, muscle weakness, edema, and chronic obstructive pulmonary disease (COPD). The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #7 as cognitively intact for daily decision making with a score of 13 out of 15. Resident #7's electronic health record (EHR) was reviewed on 3/15/2022. Observed on the order summary report was the following: busPIRone HCI Tablet 5 MG (milligrams) Give 1 tablet by mouth two times a day for anxiety and depression. Order Date: 12/20/2021 Start Date: 12/20/2021. Resident #7's comprehensive care plans (CCP) were reviewed and did not include a focus area with goals and interventions for the use of the antianxiety medication, Buspirone. Resident #7's EHR consisted of a copy of a psychiatric evaluation dated 11/12/2021. Review of the evaluation documented the consult was for an evaluation of depression because Resident #7 reported anxiety. The psychiatric physician's plan documented: start Buspar (Buspirone) 5 mg 1 tab twice daily for anxiety and depression, monitor side effects and report changes. Encourage talking and f/u (follow up) 1-2 months . Resident #7 was interviewed on 03/15/2022 at 1:50 p.m. regarding his quality of care and quality of life since he was admitted to the facility. Resident #7 stated overall he liked being at the facility and everyone treated him nice. Resident #7 became tearful several times during the interview when he discussed his family and prior work history when he experience the lost of two coworkers while on the job. Resident #7 was asked if he needed to speak with the social worker. Resident #7 stated, No it's just a lot to think this will be my home. I get some kind of anxiety medication and that helps me. I saw my family yesterday and it's just hard when they leave. On 03/16/2022 at 9:34 a.m., the licensed practical nurse (LPN) #3 who routinely provided care for Resident #7 was interviewed regarding Resident #7's moods/behaviors and medications. LPN #3 reviewed Resident #7's EHR and stated, I've only been working here for 4 days. He does receive the Buspirone as scheduled. Sometimes he declines his breathing treatments, but other than that I haven't experienced him having moods or behaviors. He seems like a nice man. He enjoys going out smoking and watches television. On 03/16/2022 at 11:30 a.m., the MDS coordinator (LPN #2) who was responsible for care plans was interviewed regarding Resident #7's care plans not including a focus area for the use of the antianxiety medication Buspirone. LPN #2 stated she would review the record and follow-up with the survey team. On 03/16/2022 at 1:30 p.m., LPN #2 returned to the conference room and stated, I reviewed the record and the care plans should have been developed for the antianxiety medication use. The above findings were reviewed with the administrator, director of nursing (DON), and corporate staff during a meeting on 03/16/2022 at 4:30 p.m. No additional information was received by the survey team prior to exit on 03/17/2022 at 12:30 p.m.2. Resident #212 was admitted to the facility with diagnoses included, but were not limited to: aftercare of left hip fracture with repair (arthroplasty), CHF (congestive heart failure), reflux, diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, high blood pressure, history of pneumonia, muscle weakness, and history of falls. The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13 indicating the resident was intact for daily decision making skills. Resident #212's clinical records were reviewed. A progress note dated 11/17/21 documented that Resident #212's blood glucose level was checked and the result read, High. The resident's clinical records were further revealed Resident #212 had been on an oral hypoglycemic medication on admission, but do to the significant side effects from the medication, it was discontinued by the physician on 11/03/21. The resident's CCP was reviewed and there was no care plan for diabetes. On 03/16/22 at approximately 11:00 AM, the MDS coordinators licensed practical nurse (LPN) #2 and registered nurse (RN) #3, were interviewed regarding the diabetes care plan for Resident #212. LPN #2 stated that Resident #212 should have a care plan for diabetes, but would check with medical records. On 03/16/22 at approximately 2:30 PM, LPN #2 and RN #3 stated that a baseline care plan for Resident #212 in the area of diabetes was had not been created or could not be located. LPN #2 stated that the baseline care plan will usually carry over to the CCP, but Resident #212 didn't have one. LPN #2 stated that Resident #212 should have had a careplan for diabetes. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #43 was admitted to the facility with diagnoses that included schizoaffective disorder, mild intellectual disabilities, major depressive disorder, paranoid schizophrenia, mood disorder, hypertension, hyperlipidemia, and obesity. The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #43 as moderately impaired for daily decision making with a score of 11 out of 15. Resident #43's electronic health record (EHR) was reviewed on 03/15/2022. Observed Resident #43's care plan was the following focus area: The resident is on diuretic therapy (Lasix) r/t (related to) edema. Date Initiated: 07/24/2020: Revision: 07/24/2020 . A review of Resident #43's EHR did not document current orders for Lasix (Furosemide). Further review of the EHR documented the Furosemide 40 mg (milligrams) order was discontinued on 10/11/2021. On 03/16/2022 at 11:30 a.m., the MDS coordinator, licensed practical nurse (LPN) #2 who was responsible for care plans was interviewed regarding Resident #43's care plans showing Resident #43 was receiving Lasix (Furosemide). LPN #2 stated she would review the record and follow-up. On 03/16/2022 at 1:30 p.m., LPN #2 stated, I reviewed the record and she was taken off the Lasix so I discontinued that care plan. The above findings were reviewed with the administrator, director of nursing (DON), and corporate staff during a meeting on 03/16/2022 at 4:30 p.m. A review of the facility's Plans of Care Policies and Procedures (Revised: 9/25/2017) documented the following: .Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in the response to current interventions aft the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being No additional information was provided to the survey team prior to exit on 03/17/2022 at 12:30 p.m. Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of eighteen residents in the survey sample, Resident #3, #43, and #17. Resident #3's care plan was not updated to include use of a scoot type wheelchair and referenced a safety helmet that was no longer used. Resident #43's care plan was not revised regarding the discontinued use of a diuretic. Resident #17's plan of care reflected use of a feeding tube and Foley catheterthat were no long in place. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included atherosclerotic heart disease, COPD (chronic obstructive pulmonary disease), hypertension, gastroesophageal reflux disease, major depressive disorder, dementia, congestive heart failure and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed Resident #3 with severely impaired cognitive skills. On 3/16/22 at 9:34 a.m., Resident #3 was observed seated in a scoot type wheelchair near the nursing desk. The resident was not wearing a safety helmet. Resident #3's plan of care (revised 8/4/21) included no problems, goals and/or interventions regarding use of the scoot wheelchair. The care plan listed the resident was at risk of falls/injury due to history of falls, anti-anxiety medication use, confusion and limited mobility. Interventions to minimize fall/injury risk included, Safety Helmet while out of bed. The plan of care documented the resident at times refused to wear the safety helmet. Interventions to promote helmet use for safety included, Encourage resident to wear helmet .Educate resident on safety risks of not wearing helmet . On 3/16/22 at 1:49 p.m., registered nurse (RN) #2 was interviewed about Resident #3's care plan regarding the wheelchair and helmet. RN #2 stated she was not sure why the scoot wheelchair was not included in the care plan. RN #2 stated she had not seen Resident #3 wear a helmet in months. On 3/16/22 at 1:51 p.m., the certified nurses' aide (CNA) #1 that routinely cared for Resident #3 was interviewed. CNA #1 stated the resident had been in the scoot type wheelchair for quite a while. CNA #1 stated Resident #3 did not use a safety helmet. On 3/16/22 at 3:05 p.m., the licensed practical nurse (LPN) #2 responsible for MDS and care plan development was interviewed. LPN #2 stated the scoot chair had not been added to the care plan. LPN #2 stated the resident's use of the helmet had been discontinued and this intervention needed to be removed from the care plan. These findings were reviewed with the administrator and director of nursing during a meeting on 3/16/22 at 4:30 p.m.2. Resident # 17 was admitted with diagnoses that included acute and chronic respiratory failure, anemia, coronary artery disease, congestive heart failure, hypertension, diabetes mellitus, hyperlipidemia, bipolar disorder, chronic obstructive pulmonary disease, dysphagia, generalized muscle weakness, PEG tube placement, and status post COVID-19. According to the most recent Minimum Data Set (MDS), a Quarterly review with an Assessment Reference Date of 1/15/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. At approximately 8:30 a.m. on 3/15/2022, Resident # 17 was observed in his room, sitting on the edge of his bed, with his breakfast tray on the overbed table in front of him. The resident was actively engaged in feeding himself. At approximately 9:00 a.m., after he completed breakfast, Resident # 17 was interviewed. Asked if he had a feeding tube, Resident # 17 said, I used to. He then lifted his shirt and pointed to a healing feeding tube entry point on his stomach. Resident # 17 went on to say they .took it out several weeks ago. Resident # 17's Electronic Health Record (EHR) included the following: 2/24/2022 - 3:38 p.m. - Nursing Progress Note - Resident returned from appointment with GI (Gastrointestinal) doctor. Peg tube removed without any problems. Orders given to place dry gauze dressing over site X (times) 3 days and change daily. Resident # 17's current care plan included the following problem, initiated on 11/29/2021, and revised on 12/6/2021, Mr. (Name of resident) requires a tube feeding r/t (related to) Dysphagia. The goal for the problem was, The resident will remain free of side effects or complications related to tube feeding through next review date. The interventions for the stated problem included, The resident needs the HOB (Head of Bed) elevated 45 degrees during and thirty minutes after tube feeding; Call MD when resident refuses tube feeding; Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed per MD orders; Listen to lung sounds every shift; Monitor/document/report PRN (as needed) any s/sx (signs, symptoms) of aspiration; Nurse to come back later and ask again to start tube feeding; Provide local care to G-Tube site as ordered and monitor for s/s of infection; RD (Registered Dietician) to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed; ST (Speech Therapy) evaluation and treatment as needed. At approximately 1:45 p.m. on 3/16/2022, licensed practical nurse (LPN) #2, who identified herself as processing Minimum Data Sets and Care Plans, was interviewed. Asked when a care plan should be modified or revised after a resident's change in condition, LPN # 2 said the care plan should be revised as soon as possible. Asked if two weeks was a reasonable time to revise a care plan, LPN # 2 indicated it was. Resident # 17's care plan also included the following problem, initiated on 11/29/2021, Mr. (Name of resident) has indwelling catheter. The goal for the problem included, The resident will show no s/sx (signs and symptoms) of Urinary infection through review date; The resident will be/remain free from catheter-related trauma through review date. Interventions for the stated problem included, Catheter: Position catheter bag and tubing below the level of the bladder and away from entrance room door; Check tubing for kinks each shift; Monitor for s/sx of discomfort on urination and frequency; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to MD for s/sx UTI (Urinary Tract Infection). Further review of Resident # 17's Quarterly MDS revealed at Section H (Bladder and Bowel), under Item H0100 (Appliances), the resident was assessed as not using any appliances, including indwelling catheter, external catheter, ostomy, or intermittent catheterization. During the interview and observation of Resident # 17 on 3/15/2022, there were no indicators of an indwelling catheter, including tubing or a collection bag. Resident # 17's Electronic Health Record (EHR) included the following: 12/10/2021 - Medication Administration Note - Status Post indwelling Foley Catheter removed, resident continues to urinate on his own without complication. During an end of day meeting at 4:00 p.m. on 3/16/2022, that included the Administrator, DON, corporate nurse consultant, and the survey team, the failure to review and revise Resident # 17's plan of care following the removal of his feeding tube and Foley catheter was discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility document review, and during the course of a complaint investigation, the facility staff failed to assess and implement interventions for the treatment and prevention of pressure ulcers for one of 18 residents in the survey sample, Resident #212. Findings include: Resident #212 was admitted to the facility with diagnoses which included, but were not limited to: aftercare of left hip fracture with repair (arthroplasty), CHF (congestive heart failure), reflux, diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, high blood pressure, history of pneumonia, muscle weakness, and history of falls. The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13 indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance from at least two staff members for most ADL's (activities of daily living), including: transfers, bed mobility, dressing, toileting, and bathing. The resident was assessed as having one unhealed pressure area that was present upon admission. Resident #212's clinical records were reviewed. An admission assessment dated [DATE] at 2:00 PM documented, .Skin for every resident complete Braden scale for predicting pressure sore risk .if skin impairment noted-initiate skin grid (pressure or non-pressure) .right buttock - open area .right toe - right great toe .admitted to facility .left hip fracture .great toe of right foot had reddened area to tip of toe. Open area noted to right inner buttock . There were no measurements or any other description of the open and reddened areas than what is listed above. A nursing skin/wound assessment for Resident #212 could not be located for the above identified areas. On 10/28/21 Resident #212 was seen by the wound doctor for the buttock wound. There was no documentation regarding the resident's toes or feet. A progress note dated 11/03/21 at 7:06 PM documented, .bilateral heel DTI (deep tissue injury) .bilateral heels floated in bed . No skin or wound assessment was found for the bilateral heel DTI. A nursing progress note dated 11/08/21 and timed 6:40 PM documented, .sacrum open area treatment in place . There was no wound assessment by nursing to describe the appearance of the wound or the size of the wound. On 11/11/21 at 1:27 PM, a nursing progress note documented, .sacral wound treatment in place . No nursing wound assessment was found to determine the wound size, characteristics, progression and/or deterioration. On 11/17/21 at 12:10 PM, a nursing progress note documented, .foul odor noted from sacrum wound .call (Name of attending physician) . There was no wound assessment information or documentation regarding the wound, other than the foul odor. According to progress notes, Resident #212 was sent out to the hospital for evaluation of the wound and concerns regarding infection. A baseline care could not be found for Resident #212's immediate care for pressure ulcers. Resident #212's CCP (comprehensive care plan) documented, .has pressure injury to sacrum .(date initiated: 11/03/21) .administer treatments as ordered (11/03/21) .assess, record and monitor wound healing (11/03/21) .weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (11/03/21) . On 03/16/22 at approximately 2:30 PM, the MDS coordinators licensed practical nurse (LPN) #2 and registered nurse (RN) #3, stated that a baseline care plan for Resident #212 for pressure ulcers could not be found or had not been completed. On 03/16/22 at approximately 5:00 PM, the DON (director of nursing) and the administrator were made aware of the above information regarding Resident #212's lack of assessment by nursing on admission. The DON was made aware of the lack of interventions for the prevention of pressure areas on admission when Resident #212 was identified as high risk for pressure concerns, and had skin impairment on admission. On 03/17/21 at 9:45 AM, Resident #212's physician was interviewed and made aware that Resident #212 did not have a baseline care plan and there was lack of interventions to prevent pressure ulcers, when Resident #212 had been identified as a high risk for pressure related problems. The physician stated that Resident #212 was a complicated diabetic and had multiple comorbitities, but stated that he thought that there was a protocol in place to identify and implement interventions upon admission. A policy/protocol titled, Clinical Guidelines Skin &Wound documented, .provide a system of for identifying skin at risk, implementing individual interventions, including evaluation and monitoring .to promote skin health and decrease worsening of/prevention of pressure injury .On admission .the resident's skin will be evaluated for baseline skin condition and document in the medical record .Licensed nurse to complete skin evaluations weekly .document in medical record .CNA to complete skin observations and report to Licensed Nurse .Licensed Nurse to document presence of skin impairment/new skin impairment when observed weekly .report changes to .physician .develop individualized goals and interventions and document on care plan .weekly skin evaluations .incontinence care, reposition frequently, relieve and protect heel pressure .monitor nutrition and hydration trends . On 03/17/21 at 10:55 AM, the DON was made aware that nursing staff failed to follow Resident #212's CCP for wound assessment documentation and failed to follow their wound protocol. The DON was asked what initial interventions should have been implemented for Resident #212. The DON stated, I would have floated the heels, turned and repositioned, sure prep if the area isn't open. The DON was made aware that the initial admission assessment was completed by an LPN and that there was no other assessment information. The DON stated that a RN is supposed to follow up on assessments completed by LPNs and stated that the facility is starting to do that now. No further information and/or documentation was presented prior to the exit conference on 03/17/22. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to label medication accurately for one of eighteen residents in the survey sample, Resident #32. Resident #32 had four pharmacy supplied cards of lorsartan potassium 25 mg (milligrams) available for use in the medication cart with no label indicating a dosage change to 50 mg. The findings include: Resident #32 was admitted to the facility with diagnoses that included hypertension, hypercholesterolemia, morbid obesity, aphasia and dementia. The minimum data set (MDS) dated [DATE] assessed Resident #32 with severely impaired cognitive skills. A medication pass was conducted on 3/15/22 at 8:34 a.m. with licensed practical nurse (LPN) #4 administering medications to Resident #32. Included in medications administered to Resident #32 was losartan potassium 25 mg (milligrams). Resident #32's clinical record documented a physician's order dated 8/13/21 for lorsartan potassium 25 mg each day for treatment of hypertension. The order was changed on 3/2/22 requiring lorsartan potassium 50 mg each day. On 3/15/22 at 10:00 a.m., LPN #4 was interviewed about the lorsartan potassium 25 mg administered to Resident #32. LPN #4 reviewed the current physician orders and stated the current order was for a 50 mg dose. LPN #4 pulled the pharmacy supply card of losartan potassium used during the medication pass. The pharmacy label indicated the lorsartan potassium was 25 mg. LPN #4 looked through the medication cart and stated she did not see a supply card for the 50 mg. There was no label on the 25 mg supply card of losartan potassium indicating a dosage change. On 3/15/22 at 3:45 p.m., the unit manager (LPN #5) was interviewed about the medication error observed with Resident #32. LPN #5 looked through the medication cart and located a supply card with thirty tablets of losartan potassium 50 mg. Upon further review of the medication cart, LPN #5 located three additional cards of losartan potassium 25 mg labeled for Resident #32. There was no sticker or any identification on the labels indicating a dosage change to 50 mg. One card had five tablets remaining, one card had one tablet remaining and a third card had six tablets remaining. The card used during the medication pass on no tablets left. On 3/15/22 at 3:22 p.m., the facility's consultant pharmacist (other staff #1) was interviewed about the four supply cards of losartan potassium 25 mg stored in the medication cart. The pharmacist stated the losartan potassium 50 mg was dispensed to the facility on 3/2/22. The pharmacist stated it was possible to use two of the 25 mg tablets for the 50 mg dose but pharmacy was required to communicate that to nursing and indicate such on the medication label. The pharmacist stated nursing could apply a sticker to the label on the 25 mg tablets indicating the dosage had been changed but only if instructed by the pharmacy. The pharmacist stated he did not know if pharmacy communicated to nursing about the label/dosage change. The facility's policy titled Reordering, Changing, and Discontinuing Orders (revised 1/1/22) documented, .Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order .If Pharmacy receives a new order that changes the strength or dose of a medication previously ordered, and there is adequate supply on hand .Pharmacy should discontinue the original order .Facility Physician/Prescriber should write the new order with new directions and Facility should enter the new order on the appropriate Medication Record Forms; and .If permitted by Applicable Law, Facility should notify Pharmacy not to send the medication and attach a 'Change in Directions' sticker to the existing quantity of medications . This finding was reviewed with the administrator and director of nursing during a meeting on 3/15/22 at 4:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure physician ordered laboratory services were obtained for 2 of 18 residents in the survey sample, Resident #43 and Resident #40. Depakote levels were not obtained for Resident #43. The facility failed to process a urine sample timely for Resident #40. The findings include: 1. Resident #43 was admitted with diagnoses that included schizoaffective disorder, mild intellectual disabilities, major depressive disorder, paranoid schizophrenia, mood disorder, hypertension, hyperlipidemia, and obesity. The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #43 as moderately impaired for daily decision making with a score of 11 out of 15. Resident #43's electronic health record (EHR) was reviewed on 03/15/2022. Observed on the order summary report was the following: depakote level every night shift every 5 month(s) starting on the 18th for 1 day(s) related to PARANOID SCHIZOPHRENIA (F20.0) Order Date: 10/17/2020 Start Date: 10/18/2020. Based on the physician orders, the Depakote levels were due on March 18, 2021, August 18, 2021, and January 18, 2022 during the survey look back period. A review of Resident #43's treatment administration records (TAR) for the period of October 2020 through March 2022 did not document the labs were completed in March 2021 and August 2021. An eMar (electronic medication administration record) progress note dated 1/19/2022 documented: Resident refused blood work for the January 18, 2022 labs. A review of Resident #43's EHR did not include the laboratory results for the Depakote levels for March 18, 2021 and August 18, 2021. The EHR consisted of a copy of Valproic Acid (Depakote) lab levels was completed on 09/30/2020. On 03/16/2022 at 3:10 p.m., the administrator and director of nursing (DON) were interviewed regarding the missing labs. The DON reviewed Resident #43's and stated she was only able to locate the 9/30/2020 lab results. The DON stated, I reviewed the (lab provider) online and did not locate the labs for March 2021 or August 2021. The DON was asked about the process for the lab orders. The DON stated the orders are placed in a lab binder and the nurse reviews the TAR each morning and then matches/verifies the order in the lab binder to make sure the lab is aware they must come in to draw the labs. The DON stated based on her review of the TAR, the labs may not have been requested. The above findings were reviewed with the administrator, DON, and corporate staff during a meeting on 03/16/2022 at 4:26 p.m. No additional information was provided to the survey team prior to exit on 03/17/2022 at 12:30 p.m. 2. Resident # 40 was admitted with diagnoses that included malignant neoplasm of the prostate, anemia, hypertension, gastroesophageal reflux disease, renal insufficiency, diabetes mellitus, hyperlipidemia, Alzheimer's Disease, seizure disorder, schizophrenia, chronic obstructive pulmonary disease, difficulty walking, generalized muscle weakness, irritable bowel syndrome, chronic kidney disease, Sickle Cell disease, and status post COVID-19. According to the most recent Minimum Data Set, a Significant Change, with an Assessment Reference Date of 2/2/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively impaired, with a Summary Score of 03 out of 15. Under Section H (Bladder and Bowel), the resident was assessed as frequently incontinent of bladder and bowel. The Progress Notes in the resident's Electronic Health Record included the following: 3/9/2022 - 12:32 p.m. - Nursing Progress Note - Report from previous shift indicated that res (resident) c/o (complained of) having the urge to urinate but being unable to 3/9/2022 - 12:48 p.m. - Nursing Progress Note - SN (Shift Nurse) spoke with MD (name) office to inform of report of res urgency without urination. MD gave verbal phone order for UA C&S (Urinalysis Culture and Sensitivity). Clean urinal given to res with instructions for a clean catch urine sample. 3/10/2022 - 6:32 a.m. - Nursing Progress Note - Clean catch urine specimen obtained for C&S per MD orders. 3/14/2022 - 1:15 p.m. - Nursing Progress Note - Received call this shift from Lab. Res had urine sent to lab for UA C&S. According to the lab, the date on the urine was 3/10/22. Lab unable to process sample due to collection date being over 24 hours ago. Lab states urine needs to be recollected and a new order needed to be put in. SN put new order for UA C&S collection to be on third shift today, 3/14/22. MD office notified of change. At approximately 10:30 a.m. on 3/16/2022, the Director of Nursing (DON) was asked why the urine sample did not get to the lab on time. The DON stated that lab specimens are put out for lab pick-up and that the lab comes by around 6:00 a.m., and sometimes earlier, except for weekends. The following entry was also included in the Progress Notes: 3/16/2022 - 2:49 p.m. - Nursing Progress Note - Attempts made to collect urine for analysis this shift, resident continent and has gone to bathroom independently, resident has been asked to please ring call light when he feels urge to urinate, made him aware of need for specimen During an end of day meeting at 4:30 p.m. on 3/16/2022, that included the Administrator, DON, corporate nurse consultant, and the survey team, the collection of the urine sample from Resident # 40 was discussed. Asked if the sample obtained that day, 3/16/2022, was the sample ordered on 3/14/2022. the DON said, Yes, I personally saw the sample. The DON went on to say, We have three days to obtain the sample. There was no further discussion regarding the urine sample.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure professional standards of practice for medication administration for one of 18 residents in the survey sample, Resident #40. Findings include: Resident #40 was admitted to the facility with diagnoses which included, but not limited to: acute/chronic kidney disease, Alzheimer's disease, diabetes mellitus, high blood pressure, chronic kidney disease and prostate cancer. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. Resident #40 was assessed with a cognitive score of 3, indicating the resident had severe impairment in daily decision making skills. On 03/15/22 at 8:55 AM, a medication pass and pour observation was conducted with LPN (licensed practical nurse) #1. As LPN #1 prepared medications for administration, LPN #1 stated that she did not have the medication Flomax 0.4 mg (milligrams) for Resident #40 to administer. LPN #1 stated that she would call the pharmacy and have the medication delivered and would administer it upon arrival. At approximately 10:00 AM, a medication reconciliation for Resident #40 was completed. The resident's current orders were reviewed and included an order for, .Tamsulosin (Flomax) 0.4 mg Give 1 capsule by mouth one time a day for enlarged prostate (order date: 09/03/21) (start date: 09/04/21) . On 03/15/22 at 11:15 AM, LPN #1 was asked if the Flomax 0.4 mg for Resident #40 had arrived from the pharmacy and if the medication had been administered. LPN #1 stated that the medication had not arrived. LPN #1 stated that she had called the pharmacy and the pharmacy told her that they did not have a current order for the Flomax 0.4 mg for Resident #40. At 11:30 AM, LPN #1 called the pharmacy again. LPN #1 asked the pharmacy when the medication was last filled/dispensed and when it was sent to the facility. LPN #1 stated there was a current order for the Flomax in Resident #40's record. The pharmacy stated that a 30 day supply was last sent on 12/30/21 and stated that the medication had been discontinued on 01/19/22. LPN #1 stated then that Resident #40 had gone out to the hospital on January 19th and was readmitted on [DATE], and that was probably why the medication was discontinued. LPN #1 stated that someone may have put the order back in the system. The resident's CCP (comprehensive care plan) was reviewed and documented, .alteration in bladder incontinence (date initiated: 09/16/21) .neurogenic disorder .encourage fluids .monitor for signs/symptoms of UTI (urinary tract infection) .monitor/document/report as needed possible causes of incontinence . Resident #40's MAR (medication administration record) was reviewed and revealed that the resident had not received the Flomax 0.4 mg on March 7th, 9th, 10th, 14th and 15th (day of medication pass observation) due to the medication not being available for administration. On 03/15/22 at 3:15 PM, LPN #4 was interviewed regarding the Flomax for Resident #40. LPN #4 stated that she did not give the medication to Resident #40 because it was not there to give. LPN #4 stated that Resident #40 did not get the medicine on March 7th, 8th, and 9th from her (the days she worked). LPN #4 was made aware that she had signed her initials on 03/08/22 indicating the medication had been given. LPN #4 stated that must have been accidental and stated that Resident #40 did not receive Flomax on the three days that she worked (March 7th, 8th or 9th). On 03/16/22 at approximately 10:00 AM, the consultant pharmacist was interviewed regarding Resident #40's Flomax order. The pharmacist stated that medications are automatically discontinued when a resident goes to the hospital and could not explain why Resident #40 still had a current order showing in the clinical record. The pharmacist stated that the facility may have had some medication (Flomax) left or a slight overage from ordering early, but stated that there is no way the facility had enough medication to get them all the way through March 15th. The pharmacist stated that there are two Flomax 0.4 mg pills in the stat box, but that is all. On 03/16/22 at approximately 3:30 PM, LPN #1 was interviewed again regarding Resident #40's Flomax. LPN #1 was made aware of the discrepancy between when the pharmacy last delivered a 30 day supply of the medication on 12/30/22, that it was being documented that Resident #40 was getting the medication, when the resident's 30 day supply should have been exhausted. LPN #1 had documented multiple times that the medication was given and was asked how a medication can be administered when the medication is not available to give. LPN #1 stated, I would have borrowed it, I know that's illegal, but if I signed I gave it, I gave it. LPN #1 was asked how many days she borrowed medication. LPN #1 could not provide an answer. LPN #1 stated that she did not take the time to call the pharmacy or pull a sticker to reorder the medication for Resident #40. On 03/16/22 at approximately 4:00 PM, the administrator and DON were made aware of the above information in a meeting with the survey team. The DON stated that staff are not supposed to borrow medications from other residents. A policy was requested on administering medications per physician's orders and borrowing medications from other residents. A policy titled, Administering Medications was presented and reviewed. The policy documented, .Medications are administered in accordance with the prescriber orders .medications ordered for a particular resident may not be administered to another resident . No further information and/or documentation was presented prior to the exit conference on 03/17/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders for two of 18 residents in the survey sample, Resident #40 and Resident #212. Resident #40 was not administered medication (Flomax) as ordered by the physician. Resident #212 was on a physician ordered fluid restriction, but there were no fluid intake records for this resident. Findings include: 1. Resident #40 was admitted to the facility with diagnoses which included, but not limited to: acute/chronic kidney disease, Alzheimer's disease, diabetes mellitus, high blood pressure, chronic kidney disease and prostate cancer. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. Resident #40 was assessed with a cognitive score of 3, indicating the resident had severe impairment in daily decision making skills. On 03/15/22 at 8:55 AM, a medication pass and pour observation was conducted with LPN (licensed practical nurse) #1. As LPN #1 prepared medications for administration, LPN #1 stated that she did not have the medication Flomax 0.4 mg (milligrams) for Resident #40 to administer. LPN #1 stated that she would call the pharmacy and have the medication delivered and would administer it upon arrival. At approximately 10:00 AM, a medication reconciliation for Resident #40 was completed. The resident's current orders were reviewed and included an order for, .Tamsulosin (Flomax) 0.4 mg Give 1 capsule by mouth one time a day for enlarged prostate (order date: 09/03/21) (start date: 09/04/21) . On 03/15/22 at 11:15 AM, LPN #1 was asked if the Flomax 0.4 mg for Resident #40 had arrived from the pharmacy and if the medication had been administered. LPN #1 stated that the medication had not arrived. LPN #1 stated that she had called the pharmacy and the pharmacy told her that they did not have a current order for the Flomax 0.4 mg for Resident #40. At 11:30 AM, LPN #1 called the pharmacy again. LPN #1 asked the pharmacy when the medication was last filled/dispensed and when it was sent to the facility. LPN #1 stated there was a current order for the Flomax in Resident #40's record. The pharmacy stated that a 30 day supply was last sent on 12/30/21 and stated that the medication had been discontinued on 01/19/22. LPN #1 stated then that Resident #40 had gone out to the hospital on January 19th and was readmitted on [DATE], and that was probably why the medication was discontinued. LPN #1 stated that someone may have put the order back in the system. The resident's CCP (comprehensive care plan) was reviewed and documented, .alteration in bladder incontinence (date initiated: 09/16/21) .neurogenic disorder .encourage fluids .monitor for signs/symptoms of UTI (urinary tract infection) .monitor/document/report as needed possible causes of incontinence . Resident #40's MAR (medication administration record) was reviewed and revealed that the resident had not received the Flomax 0.4 mg on March 7th, 9th, 10th, 14th and 15th (day of medication pass observation) due to the medication not being available for administration. On 03/15/22 at 3:15 PM, LPN #4 was interviewed regarding the Flomax for Resident #40. LPN #4 stated that she did not give the medication to Resident #40 because it was not there to give. LPN #4 stated that Resident #40 did not get the medicine on March 7th, 8th, and 9th from her (the days she worked). LPN #4 was made aware that she had signed her initials on 03/08/22 indicating the medication had been given. LPN #4 stated that must have been accidental and stated that Resident #40 did not receive Flomax on the three days that she worked (March 7th, 8th or 9th). On 03/16/22 at approximately 3:30 PM, LPN #1 was interviewed again regarding Resident #40's Flomax. LPN #1 was made aware of the discrepancy between when the pharmacy last delivered a 30 day supply of the medication on 12/30/22, that it was being documented that Resident #40 was getting the medication, when the resident's 30 day supply should have been exhausted. LPN #1 had documented multiple times that the medication was given and was asked how a medication can be administered when the medication is not available to give. LPN #1 stated, I would have borrowed it, I know that's illegal, but if I signed I gave it, I gave it. LPN #1 was asked how many days she borrowed medication. LPN #1 could not provide an answer. LPN #1 stated that she did not take the time to call the pharmacy or pull a sticker to reorder the medication for Resident #40. On 03/16/22 at approximately 4:00 PM, the administrator and director of nursing (DON) were made aware of the above information in a meeting with the survey team. A policy was requested on administering medications per the physician's order. A policy titled, Administering Medications documented, .Medications are administered in accordance with the prescriber orders .medications ordered for a particular resident may not be administered to another resident . On 03/16/22 at approximately 5:00 PM, the DON and administrator were again made aware of the above information and concerns regarding Resident #40 not receiving his physician ordered Flomax from March 7th through March 10th and on March 14th and 15th. No further information and/or documentation was presented prior to the exit conference on 03/17/22. 2. Resident #212 was admitted to the facility with diagnoses which included, but were not limited to: aftercare of left hip fracture with repair (arthroplasty), CHF (congestive heart failure), reflux, diabetes mellitus, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, high blood pressure, history of pneumonia, muscle weakness, and history of falls. The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13 indicating the resident was intact for daily decision making skills. Resident #212's physician's orders were reviewed. The resident had an order dated 10/26/21 for, 1 Liter fluid restriction daily related to CHF . The resident's MARs/TARs (medication administration records/treatment administration records) were reviewed. No fluid intake records were located. Resident #212's CNA (certified nursing assistant) documentation was reviewed for fluid intake. No records were found to evidence that the resident's fluid intake was being documented. The resident's CCP (comprehensive care plan) documented, .has potential fluid volume overload related to heart failure (date initiated: 11/03/21) .administer medications as ordered .diet as ordered .ensure all snacks and beverages offered .comply with diet and fluid restrictions .Monitor/document/report as needed any signs/symptoms of fluid overload . On 03/16/22 at approximately 5:00 PM, the administrator and director of nursing (DON) were made aware of the above concerns regarding Resident #212 having CHF, being ordered a fluid restriction on admission, and that no fluid intake records were found. The DON stated that she would look for them. The DON stated that they normally get an order and it will carry over to the MAR/TAR and they will document each shift the amount of fluid taken by the resident. The DON stated that it is usually divided out for a certain amount of fluid for each shift. On 03/17/22 at 10:55 AM, the DON stated that they did not have any intake records for Resident #212. No further information and/or documetnation was presented prior to the exit conference on 03/17/22.

Based on medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. The total number of opportunities were 35, with a total of 4 medication errors, which resulted in a medication error rate of 11.43 percent. Findings include: 1. On 03/15/22 at 8:56 AM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #40. LPN #1 pulled the resident's medications and put them into a plastic medication cup. The medications were documented and then counted for accuracy. The count did not match. The medications in the cup were 12 pills; the number of pills documented was 10. LPN #1 was asked to pull each medication pill card/bottle from the medication cart. The pill cards/bottles were compared to the pills in the cup, as well as, what was documented. Each pill card had the pill's identifying characteristics listed. LPN #1 stated that she had pulled two of the famotidine pills (20 mg each) and stated the resident is ordered 40 mg. This made the count 11. LPN #1 stated that she also pulled a folic acid pill, which would then make the count 12. As a result of the above information, each medication in the cup was verified with the pill identifying characteristics listed on the medication card or bottle. All were correct except one white pill. LPN #1 stated that the last pill in the cup was the Norvasc 5 mg tablet. The pill in the cup did not match the pill in the Norvasc 5 mg card and did not match the identifying characteristics listed on the card for Norvasc 5 mg. LPN #1 then stated that she did not know, but felt certain the pill should be the Norvasc 5 mg tablet. The pill in the cup was again compared to the pill in the Norvasc 5 mg card. LPN #1 then stated, That isn't the same pill. The pill in the cup was white, scored on one side, and had the imprint PLIVA 434. This pill was identified as a Trazadone 100 mg tablet. LPN #1 had pulled the incorrect mediation for administration. The Norvasc 5 mg pill that was ordered to be given at this time was not put in the cup for administration. LPN #1 was asked what she thought may have happened. LPN #1 stated that the Trazadone is a night time medication and she didn't pull any of those cards out. LPN #1 then stated that when she pulled the Norvasc 5 mg card out of the drawer, the first one was empty and the one behind it must have been the Trazadone card. LPN #1 stated, I must not have paid attention to that. LPN #1 had another card of the Norvasc 5 mg tablets, but no pills had been removed from the card, it was full. LPN #1 stated that Resident #40 was also supposed to get a tamsulosin (Flomax) 0.4 mg capsule, but that the medication was not available, and she would have to call the pharmacy and have it delivered and would administer it when it arrived. LPN #1 stated, .That's a med error. LPN #1 was made aware that the omission of the Norvasc 5 mg tablet and the addition of the Trazadone 100 mg tablet would count as two medication errors. A medication reconciliation was completed for Resident #40. The current physician's orders were: .Tamsulosin HCL capsule 0.4 mg give 1 capsule by mouth one time a day for enlarged prostate (9:00 AM) .amlodipine (Norvasc) tablet 5 mg give one tablet by mouth one time a day (9:00 AM) .Trazadone 100 mg give one tablet by mouth one time a day (9:00 PM) . On 03/15/22 at 11:30 AM, LPN #1 was asked about the Flomax medication. LPN #1 stated that she had called the pharmacy and that they told her that the medication was not showing up as an active order in the system. LPN #1 was made aware that the resident's physician's orders and the resident's MAR (medication administration record) both listed the the Flomax 0.4 mg capsule as a current medication for Resident #40 to be administered at 9:00 AM. LPN #1 stated that when she called the pharmacy they told her that they did not have a current order for the Floxmax 0.4 mg for Resident #40, but she knew it was a current order. At approximately 12:00 PM, LPN #1 was made aware that the due to the medication Flomax not being administered per the physician's order that would also count as a medication error. On 03/16/22 at 5:00 PM, the administrator and DON were made aware of the above medication errors. No further information and/or documetnation was presented prior to the exit conference on 03/17/22.2. A medication pass was conducted on 3/15/22 at 8:34 a.m. with licensed practical nurse (LPN) #4 administering medications to Resident #32. Included in medications administered to Resident #32 was losartan potassium 25 mg (milligrams). Resident #32's clinical record documented a physician's order dated 3/2/22 for lorsartan potassium 50 mg each day for treatment of hypertension. The resident had no current order for a 25 mg dose of losartan potassium. On 3/15/22 at 10:00 a.m., LPN #4 was interviewed about the lorsartan potassium 25 mg administered to Resident #32. LPN #4 reviewed the current physician orders and stated the order was for a 50 mg dose. LPN #4 pulled the pharmacy supply card of losartan potassium used during the medication pass. The pharmacy label indicated the lorsartan potassium was 25 mg. LPN #4 looked through the medication cart and stated she did not see a supply card for a 50 mg dose. On 3/15/22 at 3:45 p.m., the unit manager (LPN #5) was interviewed about the medication error observed with Resident #32. LPN #5 looked through the medication cart and located a supply card with losartan potassium 50 mg tablets. LPN #5 stated the 50 mg dose was available and should have been given as ordered. The policy titled, .general dose preparation of medication administration documented, .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 . This finding was reviewed with the administrator and director of nursing during a meeting on 3/15/22 at 4:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, facility staff failed to ensure a gradual dose reduction (GDR) for Ativan was attempted for one of 21 residents in the survey sample, Resident #43. Findings included: Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Alzheimer's Disease, Psychosis, Depression, and Anxiety. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/22/2019. Resident #43 was assessed as severely impaired in her cognitive status with a total cognitive score of three (03) out of 15. Resident #43's clinical record was reviewed on 11/20/2019 at 2:00 p.m. A Behavioral Health Progress Note dated 6-14-19 included, .Plan: .Ativan 0.5mg [milligrams] TiD [three times daily], consider dose reduction in Ativan . A monthly Consultation Report from the facility pharmacist dated 07/09/2019 included, .Comment: [Name] Resident #43 takes risperidone 0.5mg QHS [at bedtime], lorazepam 0.5mg TID [three times daily], and trazodone 25mg QHS. Recommendation: .please attempt a gradual dose reduction (GDR) of one or more of these agents .Physicians's Response: I accept the recommendation(s) above, please implement as written. I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): D/C Trazadone . Both options were checked by the physician, although no dose reduction recommendations had been suggested by the pharmacy. The physician signed off on this pharmacy consult on 7/10/19. Review of past medication regimen reviews dated November 2018 through October 2019 did not include any recommendations for GDR attempts for Ativan or Trazodone during this time frame. Risperidone was not started until 06/17/2019. The November [DATE] included, Ativan Tablet 0.5MG (Lorazepam). Give 0.5 mg via PEG-Tube three times a day related to Anxiety Disorder .-Start Date- 07/17/2018 . Resident #43 was currently taking this medication three times daily. No dosage reductions had been attempted since the Ativan was started July 2018. The DON (director of nursing) was interviewed on 11/20/2019 at 3:00 p.m. When asked about the Behavior Health Progress Note and the physician's recommendations, the DON stated, [Name] Medical Director looks at these. Regarding the pharmacy consult report, the DON stated, I took the notations above to mean a gradual dose reduction of one or more and he dc'd the Trazodone. On 11/21/2019 at 8:40 a.m., the pharmacist, Other #2, was interviewed via phone regarding Resident #43's pharmacy reviews. Other #2 stated, Going by memory, there may have been a contraindication. I believe going forward I will just write a note for each medicine and nothing will get lost in translation in the computer. That seems the best thing to do. Resident #43's physician, the Medical Director, was interviewed on 11/21/2019 at 8:50 a.m. via phone regarding no attempts at a GDR for Ativan. Medical Director stated, She had been in the hospital prior to coming to long term care and had been on the Ativan for quite some time. I spoke with her daughter and she was very reluctant to make any medication changes. It is unusual for me to have someone on a [NAME] [benzodiazepine] three times a day. I believe I wrote to decrease it on the November recommendation. I didn't change her Risperidone because she was having hallucinations and I thought the Risperidone would help her rest better. The Administrator was informed of the above findings during a meeting with the survey team on 11/21/2019 at approximately 9:00 a.m. No further information was received prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and resident interview, the facility staff failed to follow physician orders for the use of TED (thromboembolic deterrent) knee high compression stockings for one of 21 residents, Resident #63. The findings include: Resident #63 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension, intestinal obstruction, pulmonary embolism, chronic kidney disease - stage 3, and hyperglycemia. The most recent minimum data set (MDS) dated [DATE] was a 5-day assessment and assessed Resident #63 as moderately impaired for daily decision making with a score of 12 out of 15. Resident # 63's clinical record was reviewed on 11/20/19. Observed on the physician order sheet was the following order: TED knee high compression stockings daily, may remove at bed time, one time a day. The order date was 11/14/19 and the start date was 11/15/19. A review of Resident #63's treatment administration record (TAR) did not document the application of the stockings for the period of 11/15/19 through 11/18/19; the TAR was left blank for these days. On 11/19/19, the TAR documented the following code 9 = Other/See Nurse Notes). A review of the nurses notes on 11/19/19 did not address the order for the stockings. On 11/20/19 at 8:55 a.m., Resident #63 was observed sitting beside her bed in her wheelchair talking on the telephone. Resident #63 was observed wearing light brown anti-slip socks with grippers on the bottom. On 11/20/19 at 1:45 p.m., Resident #63 was again observed sitting beside her bed in her wheelchair wearing the light brown anti-slip socks with grippers on the bottom. On 11/20/19 at 1:45 p.m., Resident #63 was interviewed regarding the use of the ted knee high compression stockings. Resident #63 stated no I have not worn them yet. The lady doctor told me they were going to have to order a larger size for me. It's been almost a week and I haven't worn them yet. If my legs or feet swell, the girls will put my feet up or help me get in the bed. On 11/20/19 at 2:00 p.m., the certified nursing assistant (CNA #1) who was providing care for Resident #63 was interviewed regarding the TED knee high compression stockings. CNA #1 stated yes, I work with [Resident #63's name], but I didn't know she was suppose to have any TED hose on, otherwise I would have put them on her. On 11/20/19 at 2:01 p.m., the licensed practical nurse (LPN #1) was interviewed regarding the order for the TED knee high compression stockings. LPN #1 stated the CNA was responsible for applying the TED hose and then nursing would visually verify they were applied before signing off on the TAR. LPN #1 stated it could have been possible the TED hose were in the laundry. LPN #1 was asked to review Resident #63's orders and TAR and to speak with the resident as Resident #63 had stated she had not worn any TED hose since the physician wrote the order last week. LPN #1 reviewed the orders and TAR and stated she was not sure why Resident #63 had not been wearing the stockings. During this time, the central supply manager (OS #1) came to the nurses station and LPN #1 asked her if they had compression stockings in stock to fit Resident #63. OS #1 said yes we have them here. OS #1 walked to the storage area and returned with an unopened pack of compression stockings for Resident #63. OS #1 stated all someone had to do was let me know and [Resident #63's name] would have been wearing them. On 11/20/19 at 3 p.m., the director of nursing (DON) was interviewed regarding the order for the TED knee high compression stockings. The DON reviewed the electronic medical record and stated the nurse practitioner wrote the order on 11/14/19 with a start date on 11/15/19. The nurse on duty did not apply the TED hose 11/15/19 - 11/19/19 because they were unable to locate a larger size for Resident #63. The DON continued and stated when the staff determined Resident #63 needed a larger size, they failed to communicate this information with the central supply manager (OS #1). The DON stated the central supply manager told her the items were in-stock; however, she was not notified by nursing that Resident #63 needed them until today (11/20/19). The DON stated it all goes back to communication between staff, it's a work in progress. These findings were shared with the administrator, director of nursing and corporate consultant during a meeting on 11/20/19 at 5:15 p.m. No additional information was provided to the survey team prior to the exit on 11/21/19 at 9:30 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, facility staff failed to ensure two of 21 residents in the survey were free from unnecessary medications, Resident #43 and Resident #36. Findings included: Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Alzheimer's Disease, Psychosis, Depression, and Anxiety. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/22/2019. Resident #43 was assessed as severely impaired in her cognitive status with a total cognitive score of three (03) out of 15. Resident #43's clinical record was reviewed on 11/20/2019 at 2:00 p.m. A monthly Consultation Report from the facility pharmacist dated 07/09/2019 included, .Comment: [Name] Resident #43 takes risperidone 0.5mg QHS [at bedtime], lorazepam 0.5mg TID [three times daily], and trazodone 25mg QHS. Recommendation: .please attempt a gradual dose reduction (GDR) of one or more of these agents .Physicians's Response: I accept the recommendation(s) above, please implement as written. I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): D/C Trazadone . Both options were checked by the physician, although no dose reduction recommendations had been suggested by the pharmacy. The physician signed off on this pharmacy consult on 7/10/19. The DON (director of nursing) signed off on the pharmacy consult on 8/21/19. The July and August MARs (medication administration sheet) 2019 included, Trazodone HCl Tablet 50 MG [milligrams]. Give 25 mg via PEG-Tube at bedtime for dementia. -Start Date- 04/27/2018 .-D/C [discontinue] Date-08/21/2019 . Resident #43 received this medication through 08/20/2019 according to documentation on the MARs. The DON (director of nursing) was interviewed on 11/20/2019 at 3:00 p.m. regarding why the physician had signed off to discontinue the Trazodone on 7/10/19, but Resident #43 continued to receive Trazodone through 8/20/2019. The DON stated, We put these [pharmacy review reports] in [Name], Medical Director's book, usually the next day. He comes in on Wednesday and looks at them and signs off. He leaves them in his book. Someone from nursing, usually me, gets them and records the orders. I was out with pneumonia during this time [7/10/19-8/20/19] and didn't sign them off until my return. No one looked at them while I was out. My ADON [assistant director of nursing] will look at them in my absence now. The Administrator was informed of the above findings during a meeting with the survey team on 11/21/2019 at approximately 9:00 a.m. No further information was received prior to the exit conference.2. Resident 36 with diagnoses including, but not limited to: dementia, osteoporosis, macular degeneration, high blood pressure, schizoaffective disorder and depressive disorder (single episode). The resident's most current MDS (minimum data set) was an annual assessment dated [DATE]. The resident was assessed as a 3 cognitively, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as having dementia, depression and schizophrenia. The resident was assessed as receiving antipsychotic, anti-anxiety and antidepressant medications in the previous 7 day look back period. In section N0450 of this MDS, the resident was assessed as receiving antipsychotic medications on a routine basis and that a GDR had not been attempted. It was also documented that the physician had documented that a GDR was contraindicated. The GDR contraindication was for the medication Seroquel, which occurred in December of 2018. A review of Resident #36's current medications documented that the resident was receiving Buspar 5 mg (milligram) every night, Seroquel 25 mg every night, and Prozac 10 mg every day. The resident's pharmacy MMR (monthly medication reviews) documented on 06/21/18 that the pharmacist made a recommendation for a GDR for the medication Buspar. The pharmacy recommendation documented, [Name of Resident #36] is on Buspar 5 mg every night at bedtime recommendation to consider a GDR, trial discontinuation or documenting that a dose reduction is clinically contraindicated. The physician response section documented, Accept the recommendation (s) above, please implement as written. The physician signed and dated the recommendation on 06/21/18. The resident's clinical records were further reviewed and did not evidence that a GDR had actually been completed for the medication Buspar. Resident #36's current CCP (comprehensive care plan) documented, .psychoactive medication .anti-anxiety and antipsychotic .administer medication as ordered .dose reduction attempts per evaluation if clinically indicated .non drug interventions . On 11/20/19 at 1:44 PM, the DON (director of nursing) was asked if a GDR had been completed for Resident #36, as the clinical record did not indicate that a GDR had occurred. The DON stated that it had not and that she was not the DON when that happened. No further information and/or documentation was presented prior to the exit conference on 11/21/19 to evidence that a GDR was completed as recommended and ordered for Resident #36.