**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 23 residents (Resident #244), in the survey sample. The findings included: Resident #244 was originally admitted to the facility 3/10/25 after an acute care hospital stay. The admission diagnoses included; spinal stenosis, paroxysmal atrial fibrillation, restless legs syndrome, and essential hypertension. The 5-day scheduled Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/13/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #244's cognitive abilities for daily decision making were intact. On 3/11/25 at 2:10 PM during an observation tour for room [ROOM NUMBER], it was observed that there was a large area on the drywall behind the resident bed headboard that was dirty with flacking paint and gauges in the wall. It was also observed that the floor under the bed was very dirty with black marks. On 3/11/25 at 2:12 PM an interview was conducted with Resident #244. Resident #244 stated, They have people paying private pay in this facility and there is no reason the walls and floors should look like this. Resident #244 also stated, You should look at some of the other rooms, they have the same issue as well. On 3/17/25 at 5:15 PM an interview was conducted with the Administrator. The Administrator stated that there are various rooms that have issues with the drywall behind the headboard of resident's beds. The Administrator also stated that the facility has a plan in place to fix this issue. On 3/19/25 at approximately 1:04 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Nursing, [NAME] President of Operations, Minimum Data Set Coordinator, Infection Preventionist, and Director of Clinical Support. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and clinical record reviews, the facility staff failed to develop a person-centered comprehensive care plan for 2 of 23 residents (Resident #27 and #34), in the survey sample. The findings included: 1. The facility staff failed to develop a person-centered comprehensive care plan to include to dysphagia for Resident #27. Resident #27 was originally admitted to the facility 8/29/23 after an acute care hospital stay. The current diagnoses included stroke, dysphagia and adult failure to thrive. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. On 3/12/25 at approximately 4:10 PM a sign was observed above the head of the bed of Resident #27. The sign stated no straws. A review of the physician's orders failed to reveal an order for no straws and a review of the person-centered care plan dated 9/6/2023 - Present failed to identify and have interventions related to no use of straws and supervision with meals because of self-feeding impulsivity. A care plan problem identified stated (name of the resident) is receiving mechanically altered diet/Mechanical soft diet. The goal stated (name of the resident) will maintain existing weight over the next 90 days. The interventions stated, insert dentures/bridges prior to meals. Monitor and document weight. Record food intake at each meal, offer appropriate substitutes for uneaten food. Use of adaptive equipment while eating/drinking. A 12/05/23 Speech Therapist (ST) progress note stated the resident initially presented to the facility with an overall moderate oropharyngeal dysphagia, with the resident on a puree diet with thin liquids and no straws. The ST progress note further stated the resident was discharged from therapy with a mild-moderate oropharyngeal dysphagia, on a mechanical soft diet with thin liquids and no straws. The ST progress note also stated to continue to encourage supervision with meals due to self-feeding impulsivity. A final interview was conducted with the Administrator, Director of Nursing, MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. On 3/19/25 at approximately 1:10 PM the above information was provided to the above staff members. They provided no evidence and voiced no concerns. 2. The facility's staff failed to ensure Resident #34 comprehensive care plan include the use of an abdominal binder. Resident #34 was originally admitted to the facility 12/27/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Other disorders of plasma protein metabolism. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral care, personal hygiene, toileting hygiene and shower/bathe self. The care plan read that the resident is receiving Tube Feeding (TF). The goal for the resident was that he will receive adequate nutrition without side effects associated with TFs. Interventions for the resident was to check tube placement by aspiration before giving feeding and elevate head of bed. The January 2025 Physicians Order Summary (POS) read: abdominal binder apply to prevent tugging of peg tube. May remove during care and replace check skin every shift. Order date: 1/18/25 at 8:31 AM. On 3/17/25 at approximately 1:15 PM., Resident #34 was assessed by the Director of Nursing (DON) to see if his Abdominal Binder (AB) had been placed on him. The resident's Abdominal Binder was not present on his abdomen. The resident was observed grabbing the bottom of his t-shirt. The DON was observed looking for the resident's (AB) but couldn't locate it. The DON left the resident's room. On 3/17/25 at approximately 1:35 PM., Licensed Practical Nurse (LPN) #2 was observed heading to the resident's room with another staff member. LPN #2 said that she would've noticed the binder wasn't on the resident's abdomen but she didn't administer his medications to him this morning. Shortly thereafter, LPN #2 with assistance from LPN #3 applied the abdominal binder around the resident's abdomen. LPN #2 said it's important to keep the binder on the resident to keep him from pulling his peg tube out. On 3/17/25 at approximately 2:30 PM., an interview was conducted with Certified Nursing Assistant (CNA) #2. CNA #2 said that when she came on shift this morning, there wasn't a binder on the resident. On 3/17/25 at approximately 5:20 PM., during the end of day meeting with the Administrator, DON and [NAME] President of Clinical Services (VPCS). The DON said that the Abdominal Binder was in the laundry due to it being soiled. A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach. You may need a PEG tube if you have difficulty swallowing or can't get all the nutrition you need by mouth.https://my.clevelandclinic.org/health/treatments/4911-percutaneous-endoscopic-gastrostomy-peg. After percutaneous endoscopic gastrostomy (PEG) tube placement, many surgeons will place an abdominal binder to protect the tube. https://pubmed.ncbi.nlm.nih.gov/22208829/ On 3/18/25 at approximately 2:25 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant, The [NAME] President of Clinical Services (VPCS). The VPCS said, It was care planned. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to follow physician's order to ensure an abdominal binder was applied on a resident's abdomen to prevent pulling and or tugging of resident's peg tube for 1 of 23 residents (Resident #34), in the survey sample. The findings included: Resident #34 was originally admitted to the facility 12/27/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Other disorders of plasma protein metabolism. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral care, personal hygiene, toileting hygiene and shower/bathe self. The care plan read that the resident is receiving Tube Feeding (TF). The goal for the resident was that he will receive adequate nutrition without side effects associated with TFs. Interventions for the resident was to check tube placement by aspiration before giving feeding and elevate head of bed. A review of the comprehensive care plan did not mention an andominal binder. The January 2025 Physicians Order Summary (POS) read: abdominal binder apply to prevent tugging of percutaneous endoscopic gastrostomy (peg) tube. May remove during care and replace check skin every shift. Order date: 1/18/25 at 8:31 AM. On 3/17/25 at approximately 1:15 PM., Resident #34 was assessed by the Director of Nursing (DON) to see if his Abdominal Binder (AB) had been placed on him. The resident's Abdominal Binder was not present on his abdomen. The resident was observed grabbing the bottom of his t-shirt. The DON was observed looking for the resident's (AB) but couldn't locate it. The DON left the resident's room. On 3/17/25 at approximately 1:35 PM., Licensed Practical Nurse (LPN) #2 was observed heading to the resident's room with another staff member. LPN #2 said that she would've noticed the binder wasn't on the resident's abdomen but she didn't administer his medications to him this morning. Shortly thereafter, LPN #2 with assistance from LPN #3 applied the abdominal binder around the resident's abdomen. LPN #2 said it's important to keep the binder on the resident to keep him from pulling his peg tube out. On 3/17/25 at approximately 2:30 PM., an interview was conducted with Certified Nursing Assistant (CNA) #2. CNA #2 said that when she came on shift this morning, there wasn't a binder on the resident. On 3/17/25 at approximately 5:20 PM., during the end of day meeting with the Administrator, DON and [NAME] President of Clinical Services (VPCS). The DON said that the Abdominal Binder was in the laundry due to it being soiled. A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach. You may need a PEG tube if you have difficulty swallowing or can't get all the nutrition you need by mouth.https://my.clevelandclinic.org/health/treatments/4911-percutaneous-endoscopic-gastrostomy-peg. After percutaneous endoscopic gastrostomy (PEG) tube placement, many surgeons will place an abdominal binder to protect the tube. https://pubmed.ncbi.nlm.nih.gov/22208829/ On 3/18/25 at approximately 2:25 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant, The [NAME] President of Clinical Services (VPCS). An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on resident interview, staff interview, and a clinical record review, the facility staff failed to supervise each resident to prevent avoidable falls for 2 of 23 residents (Resident #36 and 294), in the survey sample. The findings included: 1. Resident #36 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The current diagnoses included spinal stenosis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were intact. The MDS assessment was not coded for toileting transfers due to her medical condition or safety concerns. On 3/13/25 at approximately 2:05 PM an interview was conducted with Resident #36. The resident stated she had a fall in the bathroom after she had completed elimination and washing her hands. The resident stated she turned to get paper towels and lost her balance. She stated Certified Nursing Assistant CNA) #1 was nearby but she was unable to render assistance to prevent the fall. A review of the nurse's notes dated 2/27/25 at 6:43 PM, revealed Resident #36 had a fall at 4:30 PM. The nurse documented the resident was observed sitting on the floor. The resident stated she lost her balance and fell, striking her head on the tile. The resident also stated, her head hurt where she hit it. The nurse further documented upon assessment there were no bumps to the head palpated, therefore the resident was assisted into the wheelchair and then to bed. An interview was conducted with CNA #1 on 3/17/25 at 4:05 PM. CNA #1 stated she was with the resident when she experienced the fall on 2/27/25 but she was unable to intervene when the resident turned and lost her balance falling to the floor. CNA #1 stated because of the size of the bathroom and the position of the resident's walker, which was between her and the resident, she was unable to get to the resident. The person centered care plan dated 1/9/2025 - Present had a care plan problem which stated (name of the resident) is at risk for injury due to falls. The goal stated minimize the risk of injury due to falls. The interventions included, communicate with oncoming shift resident's risk status - make sure resident has someone with her when she's walking, doing ADL care to aid in preventing a fall if she loses her balance and assess the need for a personal /sensor mat alarm. The resident's person centered care plan also stated (name of the resident) has the potential for health and safety concerns related to ADL needs and her mobility status. The goal stated maintain (name of the resident) safety through appropriate assistance and safety measures. The interventions included assist with toileting as needed and provide assistive device for safest mobility based on the most current transfer assistance evaluation. A final interview was conducted with the Administrator, Director of Nursing (DON), MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. The DON stated they would revisit the bathroom for appropriateness. On 3/19/25 at approximately 1:10 PM the above information was provided to the above staff members. They provided no additional information and voiced no concerns. 2. Resident #294 was originally admitted to the facility 3/3/25 after an acute care hospital stay. The current diagnoses included cellulitis of the right lower extremity and fluid retention of bilateral lower extremities. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/8/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #294's cognitive abilities for daily decision making were severely impaired. At section G00170 (Mobility) the resident was coded as requiring substantial/maximal assistance for toilet transfers. The active care plan dated 3/12/2025 - Present, had a problem which stated (name of the resident) is at risk for injury due to falls The goal stated minimize the risk of injury due to falls. The interventions included, 3/3/25 - Communicate with oncoming shift resident's risk status - resident needs constant reminders to use her call bell due to cognition, Staff to complete purposeful rounds on resident and 3/4/25 - Ensure resident is accompanied and not left alone when toileting, remind resident to please call for assistance with any ADL need. On 3/17/25 at approximately 3:30 PM an interview was conducted with Resident #294. Resident #294 stated she could speak five languages fluently. She was observed removing her shoes and attempting to put her severely edematous lower extremities onto the bed. The resident stated she had a fall but she was unable to state when or how, therefore a chart review was conducted. A nurse's note dated 3/3/25 at 6:30 PM revealed the resident was found on the floor beside her bed. The note also stated the resident was sitting on her bottom, facing her bed with her feet under her bed. The note further stated the resident said she slipped. Nonskid sock were provided to the resident, and she was encouraged to use the call bell for assistance. Another nurse's note dated 3/4/25 at 2:07 PM stated the Resident was placed on the toilet by CNA 10. and CNA #10 left the resident to get something and upon her return the resident was observed on the floor. A final interview was conducted with the Administrator, Director of Nursing (DON), MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. On 3/19/25 at approximately 1:10 PM the above information was provided to the above staff members. They provided no additional information and voiced no concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an abdominal binder was applied on a resident's abdomen to prevent pulling and or tugging of resident's peg tube for 1 of 23 residents (Resident #34), in the survey sample. The findings included: Resident #34 was originally admitted to the facility 12/27/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Other disorders of plasma protein metabolism. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral care, personal hygiene, toileting hygiene and shower/bathe self. The care plan read that the resident is receiving Tube Feeding (TF). The goal for the resident was that he will receive adequate nutrition without side effects associated with TFs. Interventions for the resident was to check tube placement by aspiration before giving feeding and elevate head of bed. A review of the comprehensive care plan does not mention an andominal binder. The January 2025 Physicians Order Summary (POS) read: abdominal binder apply to prevent tugging of percutaneous endoscopic gastrostomy (peg) tube. May remove during care and replace check skin every shift. Order date: 1/18/25 at 8:31 AM. On 3/17/25 at approximately 1:15 PM., Resident #34 was assessed by the Director of Nursing (DON) to see if his Abdominal Binder (AB) had been placed on him. The resident's Abdominal Binder was not present on his abdomen. The resident was observed grabbing the bottom of his t-shirt. The DON was observed looking for the resident's (AB) but couldn't locate it. The DON left the resident's room. On 3/17/25 at approximately 1:35 PM., Licensed Practical Nurse (LPN) #2 was observed heading to the resident's room with another staff member. LPN #2 said that she would've noticed the binder wasn't on the resident's abdomen but she didn't administer his medications to him this morning. Shortly thereafter, LPN #2 with assistance from LPN #3 applied the abdominal binder around the resident's abdomen. LPN #2 said it's important to keep the binder on the resident to keep him from pulling his peg tube out. On 3/17/25 at approximately 2:30 PM., an interview was conducted with Certified Nursing Assistant (CNA) #2. CNA #2 said that when she came on shift this morning, there wasn't a binder on the resident. On 3/17/25 at approximately 5:20 PM., during the end of day meeting with the Administrator, DON and [NAME] President of Clinical Services (VPCS). The DON said that the Abdominal Binder was in the laundry due to it being soiled. A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach. You may need a PEG tube if you have difficulty swallowing or can't get all the nutrition you need by mouth.https://my.clevelandclinic.org/health/treatments/4911-percutaneous-endoscopic-gastrostomy-peg. After percutaneous endoscopic gastrostomy (PEG) tube placement, many surgeons will place an abdominal binder to protect the tube. https://pubmed.ncbi.nlm.nih.gov/22208829/ On 3/18/25 at approximately 2:25 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant, The [NAME] President of Clinical Services (VPCS). An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on information obtained during the Antibiotic Stewardship task, staff interviews and clinical record review, the facility staff failed to have laboratory reports filed in the resident's clinical record for 1 of 23 residents (Resident #7), in the survey sample. The findings included: Resident #7 was originally admitted to the facility 12/18/23. The current diagnoses included a stroke and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/11/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 1 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were severely impaired. During the Antibiotic Stewardship task, on 3/17/25 at approximately 1:05 PM, it was identified that Resident #7 was diagnosed with a urinary tract infection on 3/10/25 at 11:35 PM, and started on an antibiotic. A further review revealed a nurse's note dated 3/07/25 at 7:58 PM which stated that Resident #7 was observed putting a cheeseburger with ketchup, mustard, and pickle into her vaginal area and complaining of pain in the area. Another nurse's note dated 3/10/2025 at 11:35 AM stated a urine specimen was obtained via catheter and the urine was very cloudy with a green milky tint and sediment. A new order was obtained on 3/10/25 at 12:13 PM to start Cipro (an antibiotic) 500 mg two times each day for seven days. On 3/17/25 a review of Resident #7's laboratory reports in the electronic record failed to reveal a urinalysis (a test conducted on urine) and urine culture and sensitivity (a test to identify microorganisms in urine) which were collected on 3/11/25. The Infection Preventionist had a copy of the urinalysis in a book that she brought to the interview on 3/17/25. The urinalysis had not been signed by a Physician or Practitioner to acknowledge the report had been reviewed. A review of the urinalysis final report was dated 3/11/25 at 11:24 PM and the culture and sensitivity final report was conveyed to the facility on 3/14/25 at 11:03 AM. A final interview was conducted with the Administrator, Director of Nursing (DON), MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. The [NAME] President of Clinical Operations (VPCO) stated the report was in the Nurse Practitioner's book waiting for a review and signature. The VPCO also stated that there is a delay in getting lab reports to the clinical record because they must be uploaded to the record because the lab's software does not interface with the facility's software. On 3/19/25 at approximately 1:10 PM the above information was provided to the above staff members. They provided no additional information and voiced no further concerns.

Based on information obtained during the Antibiotic Stewardship task, staff interviews and clinical record review, the facility staff failed to maintain a medical record which was complete and readily accessible for 1 of 23 residents (Resident #7), in the survey sample. The findings included: Resident #7 was originally admitted to the facility 12/18/23. The current diagnoses included a stroke and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/11/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 1 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were severely impaired. During the Antibiotic Stewardship task, on 3/17/25 at approximately 1:05 PM, it was identified that Resident #7 was diagnosed with a urinary tract infection on 3/10/25 at 11:35 PM, and started on an antibiotic. A further review revealed a nurse's note dated 3/07/25 at 7:58 PM which stated that Resident #7 was observed putting a cheeseburger with ketchup, mustard, and pickle into her vaginal area and complaining of pain in the area. Another nurse's note dated 3/10/2025 at 11:35 AM stated a urine specimen was obtained via catheter and the urine was very cloudy with a green milky tint and sediment. A new order was obtained on 3/10/25 at 12:13 PM to start Cipro (an antibiotic) 500 mg two times each day for seven days. On 3/17/25 a review of Resident #7's Nurse Practitioner/Physician's progress notes in the electronic record failed to reveal documentation concerning the resident's change in condition which resulted in a new orders on 3/10/25. On 3/17/25 a progress note was created but it still was not readily available on 3/19/25 at the time the survey ended. A final interview was conducted with the Administrator, Director of Nursing (DON), MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. The [NAME] President of Clinical Operations (VPCO) stated the report was in the Nurse Practitioner's book waiting for a review and signature. On 3/19/25 at approximately 1:10 PM the above information was provided to the facility's staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure enhanced barrier precautions were followed while providing wound care for 1 of 23 residents to prevent the spread of infection (Resident #10), in the survey sample. The findings included: Resident #10 was originally admitted to the facility on [DATE] and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Pressure Injury of bilateral heels. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. The care plan read that Resident #10 has a bilateral pressure injuries to his heels. Focus: The goal for the resident is that the size of the ulcer will decrease with evidence of healing over the next 90 days. Interventions for the resident include to provide wound care specialist evaluation and treat as ordered and administer dietary supplements as ordered. The Physician Order Summary (POS) Infection Control Precautions-Enhanced Barrier Notes : Instructions: Therapeutic Range: Ordering Prescriber: Nurse Pratictioner order date 1/18/25 at 8:31 AM. The Enhanced Barrier Precautions sign placed outside of the resident's door read the following: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must also: Wear gloves and a gown for the following High - Contact Resident Care Activities such as: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. A wound care observation was conducted on 3/12/25 at approximately 2:35 PM., with Licensed Practical Nurse (LPN) #2. LPN #2 was observed performing wound care on Resident #10s bilateral heels without wearing a gown as indicated on the Enhanced Barrier Precaution sign that was located near the resident's room entry door. On 3/12/25 at approximately 2:55 PM., an interview was conducted with LPN #2 concerning the above issues. LPN #2 said that she was so busy providing wound care to the resident, that she forgot to put on a gown (PPE). On 3/17/25 at approximately 1:15 PM., a brief encounter was made with the Director of Nursing (DON) concerning Resident #10. The DON said that she was aware of what happened and has since educated the staff. Enhanced barrier precautions (EBP), with the us of PPE is expanded for everyone's protection. Staff are required to use gown and during high-contact resident care activities that might result in the transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. MDROs then may be indirectly transferred from resident to resident during these high-contact activities, such as: Dressing, bathing and showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: Central line indwelling urinary catheter (IUC), feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing2 https://www.medline.com/strategies/infection-prevention/enhanced-barrier-precautions-for-nursing-homes/ On 3/18/25 at approximately 2:25 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, staff interviews, and clinical record review, the facility staff failed to ensure that resident care information was not posted to be viewed in their room for 2 of 23 residents (Resident #27 and 36), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 8/29/23 after an acute care hospital stay. The current diagnoses included stroke, dysphagia and adult failure to thrive. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. On 3/12/25 at approximately 4:10 PM a sign was observed above the head of the bed of Resident #27. The sign stated no straws. A review of the physician's orders failed to reveal an order for no straws and a review of the person-centered care plan dated 9/6/2023 - Present failed to identify and have interventions related to no use of straws. A care plan problem identified stated (name of the resident) is receiving mechanically altered diet/Mechanical soft diet. The goal stated (name of the resident) will maintain existing weight over the next 90 days. The intervention stated, Insert dentures/bridges prior to meals. Monitor and document weight. Record food intake at each meal; offer appropriate substitutes for uneaten food. Use of adaptive equipment while eating/drinking. A final interview was conducted with the Administrator, Director of Nursing, MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. The [NAME] President of Clinical Support stated the signage was not for the staff and she thought signage in a resident's room was appropriate for emergency support and to prevent family and friends from causing unnecessary problems for the resident. On 3/19/25 at approximately 1:15 PM another Clinical support staff #1 stated signage was appropriate as long as the resident and/or the resident representative directions. Clinical support staff #1's statement was acknowledged as correct but they failed to provide evidence that the signage was the resident and/or the resident representative directive. On 3/19/25 at approximately 1:10 PM the above information was provided to the above staff members. They provided no evidence and voiced no concerns. 2. Resident #36 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The current diagnoses included spinal stenosis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were intact. On 3/12/25 at approximately 4:15 PM a sign was observed above the head of the bed of Resident #36. The sign stated no blood pressures in the left arm. An interview was conducted with the resident on 3/13/25 at approximately 2:05 PM regarding the signage above the head of the bed. Resident #36 stated she believes it was placed over the bed so others would know she experiences tingling and discomfort in the left arm. Resident #36 stated she did not request the signage. A review of the physician's orders revealed an order dated 1/15/2025 which stated, Please do blood pressures in the right arm only due to severe stenosis of the left subclavian artery which will give inaccurate blood pressures. Review of the resident's person centered care plan dated 1/9/2025 - Present failed to reveal an intervention which stated blood pressures in the right arm only. A final interview was conducted with the Administrator, Director of Nursing, MDS Coordinator and three Corporate consultants on 3/18/25 at approximately 4:35 PM regarding the above information. The [NAME] President of Clinical Support stated the signage was not for the staff and she thought signage in a resident's room was appropriate for emergency support and to prevent family and friends from causing unnecessary problems for the resident. On 3/19/25 at approximately 1:15 PM another Clinical support staff #1 stated signage was appropriate as long as the resident and/or the resident representative directions. Clinical support staff #1's statement was acknowledged as correct but they failed to provide evidence that the signage was the resident and/or the resident representative directive. On 3/19/25 at approximately 1:10 PM the above information was provided to the above staff members. They provided no evidence and voiced no concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide the necessary behavioral health services for 1 of 23 residents (Resident #30), in the survey sample. The findings included: Resident #30 was originally admitted to the facility 8/19/24 after an acute care hospital stay. The admission diagnoses included; congestive heart failure, muscle weakness, pain in left shoulder, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #30's cognitive abilities for daily decision making were intact. On 3/11/25 at 1:50 PM an interview was conducted with Resident #30. Resident #30 stated, How do you think I'm doing? Would you be happy living like this? I lay here every day looking at this ceiling and they do nothing for me. I'm so fucking angry. On 3/12/25 at 2:10 PM an interview was conducted with the Administrator. The Administrator stated that Resident #30's wife and son passed away and he is having a hard time. On 3/18/25 at 2:24 PM an interview was conducted with the Administrator. The Administrator stated, No we do not have any referrals for Psych services. I spoke with the Psych Nurse Practitioner (NP), and she said that she will reach out to the NP. The Care Plan with an effective date of 8/28/24 through Present read that resident has a potential for impaired quality of life related to new environment and change in health status. The goal was resident's mood and behaviors will be monitored and managed. The interventions for Resident #30 was provide emotional support, provide non-pharmacological interventions as appropriate such as: offer fluids, offer snack, toileting, repositioning, assist as needed communication with family and friends, and monitor for safe environment and psychosocial well-being. Nursing Progress Notes included the following notations: 8/20/24 at 12:03 PM: Res reports feelings of social isolation often. 8/21/24 at 10:55 PM: Resident refusing tylenol and crestor. He stated that the tylenol gives him chest pain and the crestor gives him welts all over his body. NP made aware. She will discontinue the tylenol. 9/19/24 at 5:43 PM: Attempts made for PT evaluation on Wednesday, September 18, 2024. Patient was clear and alert when he declined PT services. Patient was able to follow the explanation and the benefits of PT interventions and ultimately determined he would not be participating. No PT indicated at this time. 10/2/24 at 11:03 PM: Resident refused some of his medications tonight. He took one of the 4 COVID meds, refused Percocet. 10/3/24 at 3:00 PM: Resident refused all medications when asked. 10/4/24 at 2:21 PM: Resident refused all medications today. 10/9/24 at 10:05 PM: Resident stated he would take his pills and when I brought them in he refused. 10/16/24 at 9:54 PM: Resident refuses to take MOM. He said he will poop when he is ready. 10/21/24 at 2:21 PM: Refused all am medication. Became very verbal abusive with cursing and yelling. 10/22/24 at 10:22 PM: Resident refused all medications this shift. 10/23/24 at 9:08 AM: Resident refused all morning meds expect percocet and metoprolol. he states nope only two pills. 10/23/24 at 9:24 PM: Resident refused his Percocet at 10pm. Accidently signed it off. Resident refused all medications for me today. 10/24/24 at 8:24 AM: NP notified of resident refusing some medications. 10/30/24 at 7:35 AM: Resident refused morning medications. Stated he's not taking anymore medications for today. 11/21/24 at 6:46 PM: Res reports feelings of social isolation often. 12/2/24 at 11:19 AM: Resident yelling in the hallway god damit to PT i pay you to push me iam not pusing myself. 12/26/24 at 12:51 PM: CNA reported that the patient had cussed her out, and was yelling at her because he wanted his tray picked up because he was finished. The CNA reported that they do come around to pick the trays up, they just wait to give everyone a chance to eat their meal, and are assisting some residents with their meal. The patient stated to the CNA that he would just start calling to the front desk to tell them to come and get his tray. Patient continued to be verbally abusive to the staff, so the staff stated that she walked away. 12/28/24 at 11:45 AM: Patient communicated during med pass I am not taking any cough syrup! Communicated to patient that I did not have cough syrup to administer at present. Assisted patient with sitting up in bed and patient became belligerent again stating that he was not taking cough syrup. This nurse communicated again that cough syrup was not being given to him at this time. Patient snatched water cup out of my hand. Patient had recurring outbursts during ADL care and when attempting to refuse care or medication. Patient was able to be redirected. No additional concerns communicated during this encounter. 1/18/25 at 12:01 PM: Resident is calling the front desk stating she's a [NAME] that she didnt page for help three cnas went to room to change him and he was not wet or dirty he than [NAME] they are liars, cna showed resident the brief. care is ongoing. 1/21/25 at 10:14 PM: Pt refused Senna this shift. 1/23/25 at 10:14 AM: Per lab refused to have labs drawn Spoke with NP [NAME]. Attempt x1 more. Placed back on schedule. 1/24/25 at 9:36 AM: Refused to have bmp,cbc and HgbA1c drawn per lab. NP [NAME] notified. 2/6/25 at 9:03 AM: Resident refused all morning medications states he not taking them today attempted two times. 2/11/25 at 10:08 PM: Pt refused Senna during evening med pass. 2/17/25 at 5:24 PM: Res reports feelings of social isolation often. 2/25/25 at 9:43 PM: Pt refused Senna this shift. 2/26/25 at 6:29 PM: SW supports IDT goals and will continue to follow resident's psychosocial needs as needed. 3/2/25 at 1:59 PM: Pt refused all medication this morning with the exception of Aspirin. No additional concerns this shift. On 3/18/25 at 5:12 PM an interview was conducted with the NP. The NP stated that residents are referred to behavioral health services when that individual is having issues such as suicidal ideations or behaviors. The NP also stated the Social Worker or Nursing screens the residents and will inform her when she should refer to Psych services. The NP further stated that she did not know that Resident #30 reported feelings of social isolation often and has been refusing medications recently. The NP lastly stated, hearing from what we have discussed, maybe we should have referred to Psych services. On 3/19/25 at approximately 1:04 PM, a final interview was conducted with the Administrator, Director of Nursing, [NAME] President of Nursing, [NAME] President of Operations, Minimum Data Set Coordinator, Infection Preventionist, and Director of Clinical Support. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on resident interview, staff interview, and clinical record review the facility's staff failed to inform the resident representative of an acute condition and the necessity start a new treatment for 1 of 24 residents (Resident 24), in the survey sample. The findings included: Resident #24 was originally admitted to the facility 4/1/21 and had never been discharged from the facility. The current diagnoses included; cognitive impairment and right wrist pain. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/6/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #24's cognitive abilities for daily decision making were moderately impaired. In sectionG (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one with walking in room, dressing and toileting, limited assistance of one with transfers, locomotion, personal hygiene and supervision of one with eating. On 4/20/21 at approximately 1:40 p.m., Resident #24 stated her side was hurting and there had been concern with the right wrist. The resident further stated x-rays had been completed approximately one week ago and she had just been told an antibiotic would be started later today for the the left side pain was pneumonia. Review of the physician/Nurse Practitioner's (NP) progress notes revealed the following; on 4/12/21 the resident's chief complaint was right wrist pain and follow-up of secretions. The narrative read Also complained of right wrist pain on movement or palpation; no trauma but is using hands more that she is in physical therapy. Has slight swelling at the base of the thumb, is able to use her hand to eat, etc. Has not tried anything to make it better but is taking routine Tylenol every morning. Tenderness on palpation to the base of thumb and fat pad. The plan x-ray of the right wrist. The 4/19/21, the physician/Nurse Practitioner's (NP) progress notes revealed the following; chief complaint; bilateral lower extremity edema, congestion and pain with breathing. Resident states she has left upper chest pain and palpation and called it pleurisy. Afebrile but an occasional cough. The plan chest x-ray to rule out pneumonia. Lasix for seven days. On 4/20/21 at approximately 3:40 p.m., an interview was conducted with Registered Nurse #1 who stated x-ray results could be found in the paper record for a resident. Further review of the clinical record revealed on 4/20/21, the NP ordered Avelox (an antibiotic) 400 milligrams by mouth once daily for 14 days for pneumonia and Lasix (a fluid pill) 40 milligrams, one by mouth daily for six days on 4/21/21 for bilateral lower extremity edema. On 4/21/21 at approximately 10:45 a.m., Resident #24's paper record was reviewed but the x-ray results were observed in the paper record; therefore an interview was conducted with the Director of Nursing (DON). The DON viewed the resident's hard chart (paper record) but was unable to locate the x-ray results. After viewing two other books, the x-ray results were located in the physician/NP's notebook. The X-ray result dated 4/13/21, was of the right wrist. The result read under impression degenerative arthritis and soft tissue swelling The report was signed by the NP 4/13/21. The second x-ray report for Resident #24 was dated 4/19/2, it was a chest x-ray which revealed rales of the left lung. The impression read mild scattered interstitial pneumonia, no tuberculosis is seem. This report had not been signed by a practitioner. The DON stated after x-rays are reviewed by the physician/NP they are to filed in the hard chart by the night shift (11 p.m. - 7 a.m.) nurse. On 4/22/21 at approximately 9:00 a.m. an interview was conducted with the resident's Power of Attorney/daughter. The daughter stated Resident #24 shared with her on 4/20/21 the NP ordered an antibiotic on her because she had pneumonia and that explained why her side was hurting. The daughter stated no one representing the facility called to inform her of new medications or of a change in her mother's status. The daughter further stated that was her major concern with the facility; communication wasn't effective and she couldn't visit her mother to see for herself. Review of the clinical record on 4/22/21 didn't reveal documentation the daughter had been notified of the changes in care related to the x-ray report and observations by the NP. On 4/22/21 at approximately 5:20 p.m., the above information was shared with the Administrator, DON, ADON and the [NAME] president of Nursing. The DON stated Resident #24's daughter should have been notified of the x-ray results and addition of new medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and clinical record review the facility staff failed to ensure for 1 of 24 residents in the survey sample, Resident #13, that the residents status was accurately reflected in the Resident Assessment. The findings included: Resident #13 was originally admitted to the facility on [DATE]. Resident #13 was discharged to another nursing home on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to Parkinson's Disease and Dementia with Lewy Bodies. Resident #13's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 03/08/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 00 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #13 as requiring extensive assistance of 1 for eating and extensive assistance of 2 for bed mobility and toilet use and total dependence of 1 for dressing and personal hygiene and total dependence of 2 for transfer and bathing. On 04/21/2021 at 5:30 p.m., an interview was conducted with the Director of Nursing. When asked if Resident #13 had contractures prior to contracting COVID and transferring to another nursing home, Director of Nursing stated, No, he was rigid due to his Parkinson's but not contracted. He was readmitted with contractures. When asked if he had been seen by therapy, DON stated, Yes. Requested Physical Therapy notes. On 04/22/2021 at 1:30 P.M., an interview was conducted with Occupational Therapist. When asked if Resident #13 had contractures to his extremities prior to his transfer to another nursing home, Occupational Therapist stated, (Resident Name) left the facility with full range of motion and came back from the COVID Unit with severe contractures. COVID Unit was at another facility. On 04/22/2021 received copies of Occupational and Physical Therapy notes. Review of therapy notes revealed the following: admission Date: 12/16/2020 Therapeutic Activities Note: PTA (Physical Therapy Assistant) performed PROM (Passive Range of Motion)/stretching to LE's (Lower Extremities) in supine into extension, pt (Patient) very resistive and unable to maintain extension in (B) (Bilateral) LE's. Pt. c/o (Complain of) pain with movement; yelling at therapist and throwing hands in the air. Pt demo (B) LE flexion contracture.; OT (Occupational) Daily Document 12/17/2020 OT Self Care/ADL's (Activities of Daily Living) Note: Pt. positioned in bed to prevent further LE contractures per OT goal.; PT (Physical Therapy) Daily Document 12/17/2020 PT Therapeutic Activities Note: BLE (Bilateral Lower Extremities) flexion contracture w (With)/ limited PROM.; OT Daily Document 12/18/2020 OT Therapeutic Activities Note: Pt. positioned in geri chair to prevent further LE contractures per OT goal.; PT Daily Document 12/18/2020 PT Therapeutic Activities Note: Attempt LE PROM, pt. contracted and resistant to motion require 2 staff to ensure pt. safety 2/2 hip flexion contractures. On 04/22/2021 requested copies of Minimum Data Sets that were completed after readmission on [DATE]. Minimum Data Sets were received. Review of Minimum Data Sets revealed the following: Minimum Data Set A2300. Assessment Reference Date Observation end date: 12-23-2020 G0400. Functional Limitation in Range of Motion Coding: 0. No impairment 1. Impairment on one side 2. Impairment on both sides A. Upper extremity (shoulder, elbow,wrist,hand) coded with 0 indicating no impairment. B. Lower extremity (hip, knee, ankle, foot) coded with 0 indicating no impairment. Minimum Data Set A2300. Assessment Reference Date Observation end date: 03-08-2021 G0400. Functional Limitation in Range of Motion Coding: 0. No impairment 1. Impairment on one side 2. Impairment on both sides A. Upper extremity (shoulder, elbow, wrist, hand) coded with 0 indicating no impairment. B. Lower extremity (hip, knee, ankle, foot) coded with 2 indicating impairment on both sides. An interview was conducted with MDS Coordinator on 04/22/2021 at 1:45 p.m. When asked how do you obtain information to complete an Minimum Data Set, MDS Coordinator stated, I look at records for look back period of time, meet the resident and talk to them. It was discussed that PT and OT documented in their notes during the period of 12/16/2020 through 12/23/2020 that Resident #13 had lower extremity contractures. Requested that MDS Coordinator review admission Minimum Data Set with Assessment Reference Date of 12/23/2020. It was discussed that the admission Minimum Data Set with the Assessment Reference Date of 12/23/2020 does not reflect the resident's contractures in his lower legs. MDS Coordinator stated, I interviewed (Resident Name.) When asked did you check Resident #13 for contractures, MDS Coordinator stated, I don't remember. On 04/22/2021 at 4:00 p.m., an interview was conducted with Assistant Director of Nursing (ADON). When asked if the admission Minimum Data Set with the Assessment Reference Date of 12/23/2020 was an accurate assessment, indicating that Resident #13 had no impairment in range of motion, ADON stated, No, should do a correction MDS to ensure it gets captured. The Administrator, Director of Nursing, Assistant Director of Nursing and Corporate Nurse were made aware of the finding at the pre-exit meeting on 04/22/2021 at approximately 6:45 p.m. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility documentation review the facility staff failed to provide physician ordered wound treatment to 1 of 24 residents in the survey sample, Resident #13. The findings included: Resident #13 was originally admitted to the facility on [DATE]. Resident #13 was discharged to another nursing home on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to Parkinson's Disease and Dementia with Lewy Bodies. Resident #13's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 03/08/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 00 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #13 as requiring extensive assistance of 1 for eating and extensive assistance of 2 for bed mobility and toilet use and total dependence of 1 for dressing and personal hygiene and total dependence of 2 for transfer and bathing. On 04/21/2021 at 2:35 p.m., in at Resident #13's bedside to observe Assistant Director of Nursing (ADON) perform wound care. ADON performed hand hygiene and applied gloves. Observed the ADON remove a dressing that was covering wounds on the residents sacrum and right buttocks. Observed 4/18 was written on the dressing. When asked how often should the treatments to the residents sacrum and right buttocks be done, ADON stated, Suppose to be done daily. Copy of Treatment Administration Record for April 2021 was requested on 04/21/2021. Copy of Wound Care Policy and Procedure was requested on 04/21/2021. Copy of Treatment Administration Record for April 2021 was received on 04/22/2021. Copy of Dressing Change (Clean) Policy was received on 04/22/2021. On 04/22/2021 at approximately 9:00 a.m., review of Resident #13's April 2021 Treatment Administration Record revealed the following: Wound Care One Time Daily Starting 03/22/2021 Order Date: 3/22/2021 Notes: Sacral Wound - apply puracol ultra powder and a small amount of anasept gel then place a Large Allevyn foam dressing once daily and prn (As Needed) soiling. Observed ADON's initials in the spaces dated for the 19th and 20th; Wound Care One Time Daily Starting 04/13/2021 Order Date: 4/13/2021 Instructions: Right buttocks: Cleanse wound, pat dry, apply puracol ultra powder and a small amount of anasept gel and cover with the large foam dressing once daily and prn soiling. Observed ADON's initials in the spaces dated for the 19th and 20th. On 04/22/2021 at 4:20 p.m., an interview was conducted with the ADON. When asked what do your initials on the treatment administration record on the 19th and 20th indicate, ADON stated, Indicates it should have been done. The ADON stated, I did the treatment on the 19th even though the dressing was dated 4/18. I saw my initials on the dressing and 4/18 but I did the treatment on the 19th. When asked were the treatments done on the 20th, ADON stated, I did not do the treatment on the 20th because the Wound Doctor was suppose to come in but because of the survey she did not come in. When asked should the treatments to the sacrum and right buttocks be done everyday, ADON stated, Yes ma'am. The Administrator, Director of Nursing, Assistant Director of Nursing and Corporate Nurse were made aware of the finding at the pre-exit meeting on 04/22/2021 at approximately 6:45 p.m. No further information was provided. Policy: Dressing Change (Clean) Dressing changes will be performed according to the physician's order. The order should include site, cleaning solution, medication (if applicable), gauze, and frequency of change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review it was determined that facility staff failed to to provide oxygen at the correct prescribed rate for one of 24 residents in the survey sample; Resident #230. The findings included: Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sepsis, acute and chronic respiratory failure with hypoxia, chronic heart failure, morbid obesity, and high blood pressure. Resident #230 did not have a completed MDS (Minimum Data Set) assessment at this time. Resident #230 was documented as being alert and cognitively intact. Review of Resident #230's current physician orders documented the following order: Oxygen 2 L (liters)/min (minute) per nasal cannula. On 4/20/21 through 4/21/21 observations of Resident #230 were conducted. The following was observed: On 4/20/21 at 2:06 p.m., Resident #230's oxygen was set to 2.5 liters. Resident #230 was laying in the bed at this time, not within reach of the oxygen concentrator. On 4/20/21 at 2:21 p.m., Resident #230's oxygen was set to 2.5 liters. Resident #230 was laying in the bed at this time, not within reach of the oxygen concentrator. On 4/21/21 at 11:26 a.m., Resident #230's oxygen was set to 2.5 liters. Resident #230 was laying in the bed at this time, not within reach of the oxygen concentrator. On 4/22/21 at 1:22 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #3, the nurse assigned to Resident #230. When asked if she could verify the liters of oxygen Resident #230's flow meter was set at, LPN #3 entered Resident #230's room and stated, It's between the 2 and the 3 so it looks like 2.5. When asked if Resident #230 was supposed to be on 2.5 liters of oxygen, LPN #3 stated that she would have to check Resident #230's chart and orders. At 1:25 p.m., LPN #3 stated that Resident #230 should have been receiving 2 liters of oxygen, not 2.5. Review of Resident #230's baseline care plan dated 4/13/21, documented Resident #230 as needing Transfer assistance when transferring to and from different surfaces: Gait belt attended by at least 1 staff member. This information shows that Resident #230 was unable to get out of bed on her own to change the oxygen dial. On 4/22/21 at 5:47 p.m., the Administrator and the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Oxygen Administration and Safety Guidelines documented in part the following: Resident are administered oxygen therapy as prescribed by physician . No further information was presented prior to exit.

Based on observation, resident interview, staff interviews, and clinical record review, the facility's staff failed to investigate underlying causes of the resident's anxiety and depression, address, review and revise the resident's behavioral health care plan and create an environment conducive for a resident with known mental health disorders who voiced a suicide attempt while hospitalized for 1 of 24 residents (Resident #130), in the survey sample. The findings included: Resident #130 was originally admitted to the facility 4/8/21 and readmitted had not been discharged from the facility. The current diagnoses included; a bipolar disorder, an anxiety disorder and chronic pain syndrome. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #130's cognitive abilities for daily decision making were intact. In section D0200 (Mood) of the MDS assessment the resident was coded as having hopelessness, little energy, feeling bad about herself and trouble concentrating 12-14 days out of 14 days; restless/fidgeting and thoughts of being better off dead 7-11 days out of 14 days. The resident's total severity score was 18 out of 27. In section E (Behaviors) the assessment was coded for behaviors not directed towards others which significantly interfered with care. In section G (Physical functioning) of the MDS assessment the resident was coded as requiring total care of one person with bathing, limited assistance of one person with transfers, walking, locomotion, dressing, toileting, and personal hygiene and supervision of one person with bed mobility and eating. On 4/20/21 at approximately 2:15 p.m. an interview was conducted with Resident #130. The resident asked if I could get a wall nurse call light for the room. The resident stated I used it too much therefore they removed it and gave me this tap bell which no one answers. Resident #130 further stated they all hate me and doesn't want to help me and they haven't been providing my Seroquel as it was prescribed. I am supposed to receive eight tablets each day. Further interview with the resident revealed she had called 911 on several occasions because staff didn't respond to her calls for assistance using the tap bell. The resident expressed I just want people to come when I call. Review of Resident #130's care plan revealed the following; 4/20/21- problem; resident is receiving an antipsychotic drugs on a regular basis for a diagnosis of Bipolar disorder. The goal read; the resident will not cause harm or injury to self or others over the next 90 days. The interventions included; medication as ordered. Record behaviors on the tracking form. Remind the resident that behaviors are not appropriate. Remove the resident from situations, allow time for her to calm down. 4/20/21- problem; the resident is receiving an antidepressant drug on a regular basis. The goal read; symptoms of depression will be controlled with minimal side effects over the next 90 days. The interventions included; Conduct one to one visits to discuss current status and adjustment to lifestyle. Monitor for side effects of medication (dry mouth, anxiety, agitation, headache and falls). Plan with the resident and physician for a trial period of dose reduction. Observe for changes in mood/ behavior, crying, sleep patterns, fatigue, appetite, ability to concentrate and participation in activities. 4/20/21- problem; Resident is receiving an antianxiety drug on an as needed basis. The goal read; symptoms of anxiety will be controlled with minimal side effects over the next 90 days. The interventions included; engage the resident in group/individual activities that reduce periods of anxiety. Resident to abstain from alcohol. Provide a quiet atmosphere with one-on-one support during periods of increased anxiety. Allow resident to talk about events and causes if known. On 4/20/21 at approximately 2:35 p.m., an interview was conducted with Certified Nursing Assistant CNA) #1. CNA #1 stated she had been told that Resident #130 attempted to commit suicide therefore a wall call bell was not in the room and to keep the tap bell on the bedside table. CNA #1 further stated the resident has poor balance, doesn't call very often, likes to do things a specific way and often complains that some staff have an attitude with her. CNA #1 stated she had not been instructed to monitor the resident any more frequently than other residents, or report specific behaviors and ensure all interactions are quiet and positive. A Nurse Practitioner's progress note date 4/8/21 stated the resident was see by psychiatry in the hospital and the medications had been adjusted. The progress note further stated the resident was in bed complaining of not having a phone, not being able to see her husband, not being able to have visitors and stated that she tried to kill herself a few days ago at the hospital by putting a plastic bag over her nose and mouth. The information was given to the Administrator and they will provide a bell in the room and take away the call light. The resident denied wanting to kill herself currently but is very upset and not answering questions, only complaining. The plan was for a psychological consult, continue current medications and treatments, discontinue as needed Seroquel, consider Risperdal if needs an antipsychotic. A progress note dated 4/11/21 at 8:11 a.m., read the Administrator received a call form the facility that the resident was making statements about wanting to die and specific comments about harming herself. Monitoring of the resident was increased and the Community Services Board (CSB) was called. The CSB instructed if the facility's staff felt the resident was a danger to herself or others to send the resident to the emergency room for evaluation. Instructions were given to the facility to transport Resident #130 to the emergency room. A Nurse Practitioner's progress note dated 4/12/21 stated the resident was suicidal and sent out to the emergency room last night and came back. The resident denies wanting to kill herself. On 4/13/21, Resident #130 was seen by the psychiatric Nurse Practitioner post an emergency room visit, for anxiety and suicidal ideation. At the hospital the resident was seen by the Psychiatrist but had no medication changes because the resident was stable. The resident was monitored for a few hours and returned back to the facility. The progress further stated the resident stated she felt good this morning because she got some rest at the hospital. The resident reported to the psychiatric Nurse Practitioner that she received Seroquel 25 milligram (mg) seven to eight times each day as needed. The psychiatric Nurse Practitioner ordered scheduled Seroquel 25 milligram three times each day. The psychiatric Nurse Practitioner's recommendation included; monitor for changes in mood, mental status, behaviors, pain, appetite/weight, sleep, safety/safety awareness, AIMS assessment per nursing protocol. Continuous non-pharmacological interventions to include; maintain a quiet and stress-free environment, gentle redirection and reassurance, reinforcement of self efficacy. Identify, address and eliminate underlying causes of distress and or behavioral disregulation. On 4/13/21 the resident's psychoactive medications are as follows; Seroquel 25 mg three times each day, Buspirone 30 mg twice a day, Clonazepam 1 mg at bedtime, Carbamazepine 400 mg daily, and Nefazodone 50 mg daily. On 4/22/21 at approximately 11:00 a.m., observation of Resident #130's room revealed the following; no wall call bell but a tap bell which was not answered when tapped. A string hanging from the over the bed light attached to the bed rail. Mini blind strings at the window, a Food Lion plastic bag on the chest of drawers beneath the television, a large plastic bag in a hamper to hold soiled linen, a trash can beside the bed with a plastic bag and a trash can in the bathroom with a plastic bag. On the resident's meal tray was all disposable products including plastic utensils which could be broken and used as sharp instruments. The resident was also noted to be in a room at the distal corridor from the nurse's station and absent of high traffic. The above items were potential items to use for suicide but during the resident's thirteen days of having them in her presence didn't attempt to utilize them to harm herself. On 4/22/21 at approximately 3:00 p.m., an interview was conducted with CNA #4. CNA #4 stated they were not instructed to do more frequent monitoring of the resident or attempts to engage her in activities, report warning signs such as negative statements, mood swings, etc. CNA #4 could only recall removal of the wall call light and use of disposable products on the meal tray related to the resident's suicidal ideation. On 4/22/21 at approximately 5:20 p.m., the above information was shared with the Administrator, DON, ADON and the [NAME] president of Nursing. The DON stated Resident # 130's psychological services are being addressed but we can do more to produce a therapeutic environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and facility documentation review the facility staff failed to remove expired medication from 1 of 2 medication carts (Cart A). The findings included: On [DATE] at 11:30 a.m., during inspection of Medication Cart A observed Advair Diskus box and on the outside of the box the date [DATE] was written. Requested to see Advair Diskus box. When asked what does the date [DATE] indicate, Licensed Practical Nurse (LPN) #1 stated, That was when it was opened. Review of the label on the box revealed the following: Advair Diskus AER 250/50 60 AEPB [DATE] 1 PUFF BY MOUTH TWICE A DAY - RINSE MOUTH AFTER EACH USE DISCARD WHEN COUNTER READS 0 OR 30 DAYS AFTER FOIL POUCH IS OPENED, WHICHEVER COMES FIRST. Requested that LPN #1 remove the Advair Diskus from the box. Observed that the Advair Diskus was not in a foil pouch and [DATE] was written on the diskus. Requested that LPN #1 review the label on the Advair Diskus box. When asked when should the Advair Diskus have been discarded, LPN #1 stated, 30 days after opening. When asked was it discarded, LPN #1 stated, No. On [DATE] at approximately 8:30 a.m., a copy of the Medication Administration Policy and Procedure was requested. On [DATE] at approximately 10:00 a.m., a copy of Medication Administration Guidelines was received. The Administrator, Director of Nursing, Assistant Director of Nursing and Corporate Nurse were made aware of the finding at the pre-exit meeting on [DATE] at approximately 6:55 p.m. No further information was provided. Titled: Medication Administration Guidelines Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Administration: . If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal.

Based on resident interview, staff interview, and clinical record review the facility's staff failed to file in the resident's clinical record signed and dated x-ray reports dated 4/13/21 and 4/19/21 for 1 of 24 residents (Resident 24), in the survey sample. The findings included: Resident #24 was originally admitted to the facility 4/1/21 and had never been discharged from the facility. The current diagnoses included; cognitive impairment and right wrist pain. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/6/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #24's cognitive abilities for daily decision making were moderately impaired. In sectionG (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one with walking in room, dressing and toileting, limited assistance of one with transfers, locomotion, personal hygiene and supervision of one with eating. On 4/20/21 at approximately 1:40 p.m., Resident #24 stated her side was hurting and there had been concern with the right wrist. The resident further stated x-rays had been completed approximately one week ago and she had just been told an antibiotic would be started later today for the the left side pain was pneumonia. Review of the physician/Nurse Practitioner's (NP) progress notes revealed the following; on 4/12/21 the resident's chief complaint was right wrist pain and follow-up of secretions. The narrative read Also complained of right wrist pain on movement or palpation; no trauma but is using hands more that she is in physical therapy. Has slight swelling at the base of the thumb, is able to use her hand to eat, etc. Has not tried anything to make it better but is taking routine Tylenol every morning. Tenderness on palpation to the base of thumb and fat pad. The plan x-ray of the right wrist. The 4/19/21, the physician/Nurse Practitioner's (NP) progress notes revealed the following; chief complaint; bilateral lower extremity edema, congestion and pain with breathing. Resident states she has left upper chest pain and palpation and called it pleurisy. Afebrile but an occasional cough. The plan chest x-ray to rule out pneumonia. Lasix for seven days. On 4/20/21 at approximately 3:40 p.m., an interview was conducted with Registered Nurse #1 who stated x-ray results could be found in the paper record for a resident. On 4/21/21 at approximately 10:45 a.m., Resident #24's paper record was reviewed but the x-ray results were observed in the paper record; therefore an interview was conducted with the Director of Nursing (DON). The DON viewed the resident's hard chart (paper record) but was unable to locate the x-ray results. After viewing two other books, the x-ray results were located in the physician/NP's notebook. The X-ray result dated 4/13/21, was of the right wrist. The result read under impression degenerative arthritis and soft tissue swelling The report was signed by the NP 4/13/21. The second x-ray report for Resident #24 was dated 4/19/2, it was a chest x-ray which revealed rales of the left lung. The impression read mild scattered interstitial pneumonia, no tuberculosis is seem. This report had not been signed by a practitioner. The DON stated after x-rays are reviewed by the physician/NP they are to filed in the hard chart by the night shift (11 p.m. - 7 a.m.) nurse. On 4/22/21 at approximately 5:20 p.m., the above information was shared with the Administrator, DON, ADON and the [NAME] president of Nursing. The DON stated she had no additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to document that one of 24 residents; Resident #231 received a bed bath on 4/16/21 and 4/17/21. The findings included: Resident #231 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, cerebral palsy, high blood pressure, stroke, and altered mental status. Resident #37 did not have a completed MDS (Minimum Data Set) assessment at this time. On 4/20/21 through 4/21/21 this writer had several interactions with Resident #231. Resident #231 had periods of confusion during these interactions. On 4/20/21 at 1:17 a.m., an interview was conducted with Resident #231. When asked if she received showers, Resident #231 stated, Don't know. I am not sure when I am supposed to get showers. When asked if she received bed baths, Resident #231 stated that sometimes staff provided bed baths. Review of Resident #231's ADL (Activity of Daily Living) care plan documented the following for bathing: Assist (Name of Resident #231) with bathing as needed. Review of Resident #231's ADL (Activities of Daily Living) flow chart for bathing failed to evidence that Resident #231 received a bed bath on 4/16/21 and 4/17/21. There were concerns related to receiving showers. On 4/22/21 at 3:14 p.m., an interview was conducted with CNA #2, the nursing aide assigned to Resident #231 on 4/16/21 and 4/17/21. CNA #2 stated that residents received bed baths everyday unless it was a scheduled shower day. When asked if showers/baths should be documented in the clinical record, CNA #2 stated that they should. When asked if Resident #231 was provided a bed bath or shower on 4/16/21 and 4/17/21, CNA #2 stated that she could not recall, that a bed bath was probably given and she probably forgot to document. CNA #2 also stated that sometimes when she charted late, the system would kick her out and she was unable to chart. On 4/22/21 at 5:47 p.m., the Administrator and the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Medical Records, documented in part, the following: A complete, timely, and accurate resident record is created and maintained for each resident .Every entry in the medical record must be legible, complete, and is authenticated and dated by the person responsible for ordering, providing or evaluating the service in a prompt manner. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility documentation review the facility staff failed to maintain infection control practices for 2 residents in the survey sample, (Resident #8 and #231. The findings included: 1. Staff failed to clean over bed table after removing metal tray. 1. Resident #8 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Anxiety Disorder and Hypertension. Resident #8's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 02/25/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 01 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #8 as requiring limited assistance of 1 for eating and personal hygiene, limited assistance of 2 for dressing, extensive assistance of 1 for toilet use, extensive assistance of 2 for bed mobility and transfer and total dependence of 1 for bathing. On 04/21/2021 at 10:07 a.m., standing at treatment cart in hallway and observed Assistant Director of Nursing (ADON) obtain treatment supplies and place them on a barrier lined metal tray. ADON walked from treatment cart down to Isolation Storage Bins sitting in hallway outside of room [ROOM NUMBER] and sat the metal tray down on the Isolation Storage Bin. The ADON then picked the metal tray up and took it into room [ROOM NUMBER] and placed the metal tray down on Resident #8's over bed table. ADON performed hand hygiene, applied gloves, removed the residents old dressing. ADON removed her gloves and performed hand hygiene. ADON applied clean gloves and cleaned wound on right heel with Normal Saline and patted area dry with dry dressing. ADON removed gloves and performed hand hygiene. ADON applied clean gloves and applied iodine soaked gauze to wound bed and covered with dry dressing, wrapped kling gauze around dressing, dated tape and applied tape to kling gauze. ADON removed gloves and performed hand hygiene. ADON picked up discarded trash and metal tray and walked out to cart. ADON disposed of trash and cleaned metal tray with germicidal wipes. ADON performed hand hygiene. When the ADON was asked if she had completed the procedure, ADON stated, Yes. On 04/21/2021 at approximately 11:30 a.m., an interview was conducted with the ADON. Discussed observations while preparing to do wound care, placing metal tray on Isolation Bin in hallway and then placing the metal tray on the residents over bed table. The ADON stated, I should have cleaned the bedside table after removing the tray. When asked what can occur when placing the metal tray on the Isolation Bins in the hallway and then placing on the resident over bed table, ADON stated, Infections and germs can occur. The Administrator, Director of Nursing, Assistant Director of Nursing and Corporate Nurse were made aware of the finding at the pre-exit meeting on 04/22/2021 at approximately 6:45 p.m. No further information was provided. 2. Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sepsis, acute and chronic respiratory failure with hypoxia, chronic heart failure, morbid obesity, and high blood pressure. Resident #230 did not have a completed MDS (Minimum Data Set) assessment at this time. Resident #230 was documented as being alert and cognitively intact. Review of Resident #230's hospital discharge report dated 4/12/21, revealed that her last COVID test was conducted on 4/7/21 and was negative. Review of Resident #230's clinical record revealed that Resident #230 was placed on the warm Observation unit upon admission into the nursing facility. On 4/20/21 at 2:50 p.m., an observation was made of Resident #230. Resident #230 had a sign outside her door with the following documentation: Let's protect each other WARM PPE required when with me . A picture of an N95 mask, face shield, gloves and gown were also displayed on the sign. A medical mask is acceptable for staff not currently fitted with an N95. On 4/21/21 at 11:25 a.m., an observation was made of OSM (Other Staff Member) #1, the housekeeper. OSM #1 was observed walking into Resident #230's room wearing a surgical mask, hair net, shield and gloves. OSM #1 did not have a gown on. OSM #1 swept around Resident #230's bed, approximately one foot away from the resident. On 4/21/21 at 11:30 a.m., an interview was conducted with OSM #1. When asked what she is supposed to wear when going into a quarantine room, OSM #1 stated that if she was touching the resident's belongings she would have worn a gown. OSM #1 stated that when she comes back to do the bathrooms, she will be wearing gown. On 4/21/21 at 1:22 p.m. LPN (Licensed Practical Nurse) #3 was asked to verify Resident #230's oxygen settings. LPN #3 entered Resident #230's room wearing a face shield and N95 mask only. LPN #3 failed to don a gown and a pair of gloves prior to entering the room. LPN #3 was less than three feet away from Resident #230's bed when checking the oxygen concentrator. On 4/21/21 at 1:25 p.m., an interview was conducted with LPN #3. When asked if Resident #230 was on quarantine, LPN #3 stated, I am not sure when her admission date was, I would have to check. LPN #3 stated that Resident #230 was on warm room precautions when she first arrived to the facility. When asked what warm room precautions meant, LPN #3 stated that a gown, shield, face mask and gloves were required to be worn while working with the resident. LPN #3 then stated that Resident #230's admission date was 4/12/21. When asked if that meant Resident #230 was still on observation for signs and symptoms related to COVID, LPN #3 stated that she wouldn't know, that this writer would have to ask the unit manager. When asked how she would know what protective gear to wear for each resident while working with them; LPN #3 stated that signs were usually posted in front of each door who was considered Warm and on observation. This writer pointed out the sign on Resident #230's door. When asked what should be worn when entering Resident #230's room, LPN #3 stated that she didn't think of it, that she didn't go into the room to provide care or even touch the resident, so she didn't think to put on a gown and gloves. LPN #3 stated, If I was going to be close to her, I'd consider it. On 4/21/21 at 2:16 p.m., an interview was conducted with ASM (Administrative Staff Member) #5, the DON (Director of Nursing). When asked what PPE was required prior to entering a room of a resident on observation or on Warm Precautions, ASM #5 stated that staff should be putting on a gown, gloves, shield and face mask. When asked if this was still true if the staff did not touch the resident while in the room, ASM #5 stated, If they are not touching her, they don't have to wear the gown and gloves. When asked how COVID was spread, ASM #5 confirmed it was by droplet transmission. When asked at what point do staff need to don a gown and a pair of gloves (How many feet from the resident), ASM #5 stated, Oh I thought you meant if they were just popping their head in the room. Staff should be wearing a gown and gloves when entering the room. On 4/22/21 at 9:49 a.m., an interview was conducted with ASM #2, the ADON (Assistant Director of Nursing) who is the ICP (Infection Control Preventionist) When asked how it is determined if a resident needs to be on precautions for observation upon admission, ASM #2 stated that if a resident is not vaccinated against the COVID-19 virus, or have only received one vaccination; they have to be on quarantine for 14 days. ASM #2 stated that if a resident does receive the second vaccination but two weeks have not gone by since last vaccination and prior to admission, they are also placed on quarantine. ASM #2 confirmed that Resident #230 was still on quarantine. When asked what PPE was required prior to entering Resident #230's room, ASM #2 stated a gown, gloves, N95 mask and face shield. When asked if a gown and gloves were required even if the caregiver does not touch anything, ASM #2 stated that since COVID-19 was airborne, you would want to also wear a gown and gloves while in close proximity to the resident. ASM #2 also stated that once in the resident's room, the caregiver doesn't know what the resident may ask them to do, get for them etc. ASM #2 stated that it was recommended to wear all required PPE before entering a resident's room on quarantine. On 4/22/21 at 5:47 p.m., the Administrator and the DON (Director of Nursing) were made aware of the above concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to ensure Resident #26 was given the opportunity to formulate an Advance Directive. Resident #26 was admitted to the facility on [DATE]. Diagnosis for Resident #26 included but not limited to Acute Kidney Failure. Review of Resident #26's Physician Order Sheet (POS) for April 2021 revealed the following order: Full Code starting on 04/02/21. The review of Resident #26's clinical record did not show evidence of an Advance Directive. On 04/22/21 at approximately 8:45 a.m., a phone interview was conducted with the Social Worker (SW) who said if a resident is their own representative, they are asked if they have an Advance Directive and if so, to provide a copy for their clinical record. If the resident is not their own representative or not able to make their own decision, then their representative is asked to provide a copy of their Advance Directive. The Social Worker said there is an Advance Care Planning document which is part of the admission packet. The surveyor and the SW reviewed Resident #26's clinical record together but was not able to locate the an Advance Care Planning document, an Advance Directive or documentation that an Advance Directive was discussed with Resident #26 or her representative. When asked if Resident #26 was given the Advance Care Planning document or asked if they wanted information related to an Advance Directive, she replied, Not with me, I did not bring it up. The Administrator, Director of Nursing, Assistant Director of Nursing and Cooperate Nurse were informed during the debriefing on 04/22/21 at approximately 5:40 p.m. The facility did not present any further information about the findings. The facility provided the following document: Advance Care Planning Assessment that read in part: Residents and/or responsible health care decision makers should be provided the opportunity to discuss advance care planning with appropriate staff members and medical providers within the first few days of admission to the facility, at times in condition, and periodically for routine updating of care plans. 3. Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sepsis, acute and chronic respiratory failure with hypoxia, chronic heart failure, morbid obesity, and high blood pressure. Resident #230 did not have a completed MDS (Minimum Data Set) assessment at this time. Resident #230 was documented as being alert and cognitively intact. Review of Resident #230's admission orders revealed a DNR (Do Not Resuscitate) order. This order was initiated on 4/12/21. Review of Resident #230's DDNR (Durable Do Not Resuscitate Order) form signed by the resident and dated 4/9/21 documented in part, the following: The patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment. On 4/20/21 at 2:06 p.m., an interview was conducted with Resident #230. She could not recall anything about an advanced directive. There was no evidence in Resident #230's clinical record showing that advanced directives were discussed with Resident #230 and whether she had already executed an advanced directive or given the opportunity to formulate one. On 4/22/21 at 9:16 a.m., an interview was conducted with OSM (Other Staff Member) #2, the facility social worker. When asked if she had a role in discussing advanced directives with residents, OSM #2 stated that upon admission the only thing she will do is inquire if the resident already has an advanced directive and if so she will request that a family member bring it in. OSM #2 stated that if the resident is not cognitively intact, she will mail a form to the RP (Responsible Party) requesting that the advanced directive be brought into the facility if one has already been developed. OSM #2 stated that she didn't actually go over how to formulate an advanced directive with residents. OSM #2 stated she wasn't sure the staff member responsible for assisting with formulating an advanced directive. On 4/22/21 at 9:27 a.m., an interview was conducted with ASM #1, the facility Administrator. ASM #1 stated that the resident's provider (physician) will usually go over advanced directives with each resident, such as what their wishes are for treatment etc. ASM #1 stated that not all the time will the provider document this discussion. Review of Resident #230's provider notes dated 4/12/21 and 4/15/21, failed to evidence that Resident #230 was given the opportunity to formulate an advanced directive. On 4/22/21 at 5:47 p.m., the Administrator and the DON (Director of Nursing) were made aware of the above concerns. 4. Resident #231 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, cerebral palsy, high blood pressure, stroke, and altered mental status. Resident #231 did not have a completed MDS (Minimum Data Set) assessment at this time. On 4/20/21 through 4/21/21 this writer had several interactions with Resident #231. Resident #231 had periods of confusion during these interactions. Review of Resident #231's POS (physician order summary) revealed the following order: Full Code. This order was initiated on 4/12/21. There was no evidence in Resident #231's clinical record showing that advanced directives were discussed with Resident #231 or her representative and whether she had already executed an advanced directive or given the opportunity to formulate one. On 4/22/21 at 9:16 a.m., an interview was conducted with OSM (Other Staff Member) #2, the facility social worker. When asked if she had a role in discussing advanced directives with residents, OSM #2 stated that upon admission the only thing she will do is inquire if the resident already has an advanced directive and if so she will request that a family member brings it in. OSM #2 stated that if the resident is not cognitively intact, she will mail a form to the RP (Responsible Party) requesting that the advanced directive be brought into the facility if one has already been developed. OSM #2 stated that she didn't actually go over how to formulate an advanced directive with residents. OSM #2 stated she wasn't sure the staff member responsible for assisting with formulating an advanced directive. On 4/22/21 at 9:27 a.m., an interview was conducted with ASM #1, the facility Administrator. ASM #1 stated that the resident's provider (physician) will usually go over advanced directives with each resident, such as what their wishes are for treatment etc. ASM #1 stated that not all the time will the provider document this discussion. Review of Resident #231's provider notes dated 4/15/21, failed to evidence that Resident #231 was given the opportunity to formulate an advanced directive. On 4/22/21 at 5:47 p.m., the Administrator and the DON (Director of Nursing) were made aware of the above concerns. Based on medical record reviews, staff interviews and facility document review the facility staff failed to ensure that 5 of 24 residents in the survey sample were allowed to participate in and/or formulate an advance directive upon admission, Residents #180, #181, #230, #231 and #26. The findings included: 1. Resident #180 was admitted to the facility on [DATE] with diagnoses to include but not limited to Right Femur Fracture, Hypertension and Spina Bifida. Due to Resident #180 being a new admission the Minimum Data Set was not scheduled to be started until 4/20/21 therefore a current Brief Interview for Mental Status was not available. However, based on nursing notes and an initial interview with Resident #180 she was determined to be alert and oriented. During a review of Resident #180's electronic medical record I was unable to locate an Advance Directive or documentation to show the facility discussed or helped to formulate an Advance Directive for the resident. Resident #180's Physician Orders were reviewed and are documented in part, as follows: Full Code Notes: Instructions: Order Date: 4/14/2021. On 4/22/21 at 11:10 A.M. a phone interview was conducted with the Administrator and the Director of Nursing regarding Resident #180's Advance Directives being formulated upon admission. The Administrator was asked if the facility discussed or helped formulate Advance Directives for Resident #180 and completed the Initial Assessment for Advance Directives form and if so where was it located in Resident #180's medical record. The Administrator stated, No, the Advance Directive Form is not in there, (the medical record). The Administrator stated, We do discuss it with them whether it be the Doctor, Nurse Practitioner or admissions and it is documented by someone. We have a solid process that it was discussed and what the outcome was. Everything we have we have sent to you. The facility policy titled Advance Directives last reviewed 1/10/12 was reviewed and is documented in part, as follows: Policy: Advance Directives will be discussed with resident and/or family member upon admission or as soon as clinically appropriate so the resident's wishes, with respect to life prolonging treatments, can be documented in the medical record. Procedure and Advance Directives will be: 1. The admissions staff/social worker will attempt to obtain Advance Directives information from the resident, family and/or hospital staff during the admission process and document the information on the Initial Assessment for Advance Directives form. If advance directive information is provided, then this information will be placed in the resident's medical record. On 2/22/21 at 5:45 P.M. a pre-exit debriefing was conducted with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided. 2. Resident #181 was admitted to the facility on [DATE] with diagnoses to include but not limited to Stage 3 Chronic Kidney Disease, Acute Kidney Failure and Hypertension. Due to Resident #181 being a new admission the Minimum Data Set was not scheduled to be started until 4/22/21 therefore a current Brief Interview for Mental Status was not available. However, based on nursing notes and an initial interview with Resident #180 she was determined to be alert and oriented. During a review of Resident#181's electronic medical record I was unable to locate an Advance Directive or documentation to show the facility discussed or helped to formulate an Advance Directive for the resident. Resident #181's Physician Orders were reviewed and are documented in part, as follows: Do Not Resuscitate Notes: Instructions: Order Date: 4/16/2021. On 4/22/21 at 11:10 A.M. a phone interview was conducted with the Administrator and the Director of Nursing regarding Resident #181's Advance Directives being formulated upon admission. The Administrator was asked if the facility discussed or helped formulate Advance Directives for Resident #181 and completed the Initial Assessment for Advance Directives form and if so where was it located in Resident #181's medical record. The Administrator stated, No, the Advance Directive Form is not in there, (the medical record). The Administrator stated, We do discuss it with them whether it be the Doctor, Nurse Practitioner or admissions and it is documented by someone. We have a solid process that it was discussed and what the outcome was. Everything we have we have sent to you. The facility policy titled Advance Directives last reviewed 1/10/12 was reviewed and is documented in part, as follows: Policy: Advance Directives will be discussed with resident and/or family member upon admission or as soon as clinically appropriate so the resident's wishes, with respect to life prolonging treatments, can be documented in the medical record. Procedure and Advance Directives will be: 1. The admissions staff/social worker will attempt to obtain Advance Directives information from the resident, family and/or hospital staff during the admission process and document the information on the Initial Assessment for Advance Directives form. If advance directive information is provided, then this information will be placed in the resident's medical record. On 2/22/21 at 5:45 P.M. a pre-exit debriefing was conducted with the Administrator and the Director of Nursing where the above information was shared. Prior to exit no further information was provided.

Based on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to ensure a resident displaying mental health concerns received the care and services to address identified concerns (staying in a totally dark room most of the time, social isolation, no interest and withdrawal) for 1 of 24 residents (Resident #16), in the survey sample. The findings included: Resident #16 was originally admitted to the facility 3/15/21 and had never been discharged from the facility. The current diagnoses included; severe anxiety, depression and dementia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/22/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #16's cognitive abilities for daily decision making were intact. In section D0200 (Mood) the resident was coded as having little to no interest, depressed, little energy and trouble concentrating 12-14 days out of 14 days; sleeping too much 7-11 days out of 14 days, and feeling bad about himself 2-6 days out of 14 days. The resident's total severity score was 15 out of 27. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing and supervision of one person with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene and independent after set-up with eating. Review of the person-centered Care Plan revealed the following; 3/26/21- problems; Resident has little interest or pleasure in doing things; social interaction. The goal read Resident will show interest and willingness to socialize with others over the next 90 days. The interventions included; Resident to eat all meals in the dining room as tolerated. Encourage family visitors to eat with the resident. Assist resident to activities and social events. Assist the resident to establish compatible relations with others. 3/26/21- problem; Resident has no involvement in activities. The goal; Resident will participate in group and/or individual activities 2-3 times per week as tolerated over the next 90 days. The interventions included; Involve resident in appropriate social groups at meals. Provide a copy of activity schedule and allow resident to choose activities. Provide room visits 2-3 times per week to establish friendship and trust. 3/26/21- problem; Resident has trouble falling or staying asleep or sleeping too much. The goal; Resident will verbalize adequate sleep/rest over the next 90 days. The interventions included; allow the resident extra time in the morning before starting care/activities. 3/26/21- problem; Resident has trouble staying asleep. The goal; A sleep/wake cycle that is acceptable to the resident will be achieved. Delayed bedtime until resident is drowsy and ready to sleep. Engage in active daytime recreation/exercise program; minimize daytime sleeping events. Provide an environment conducive to sleep (minimize noise and light, verify with resident if the temperature is comfortable). Reduce eliminate intake of caffeine. 3/26/21- problem; Resident states feeling down, depressed or hopeless. The goal; Periods of sadness will be reduced over the next 90 days. The interventions included; Assess and record behaviors. Assess changes in mental status. Discuss with physician and team a trial period of antidepressant medication therapy. The above care plan goals and interventions were no person-centered to reflect Resident #16. Review of the Nurse Practitioner's progress notes revealed on 3/16/21 a psychological consult was recommended. The resident was admitted to the facility receiving Clonazepam 2 milligram by mouth at bed time, Fluoxetine 40 milligrams by mouth each morning and Olanzapine 7.5 milligrams at bed time. As of 4/22/21 the psychological consult had not transpired. On 4/20/21 at approximately 1:05 p.m., during the initial tour Resident #16 was observed in his room with the door closed completely, in bed with the bed linens over the entire body, the window blinds completely closed, and the lights off. The resident stated my stomach is bothering me. On 4/21/21 at approximately 11:00 a.m., Resident #16 was again observed in his room with the door closed completely, in bed with the bed linens over the entire body, the window blinds completely closed, and the lights off. He answered the knock at the door and was easily engaged in conversation. The resident stated he spent most of his days in bed at home and felt it was more related to depression than a physical illness. The resident stated he didn't know if he could defeat the depression and there was no desire to harm himself or others. On 4/21/21 at approximately 3:00 p.m., certified nursing assistant #4 was interviewed. CNA #4 stated Resident #16's mood hadn't changed; she stated the resident never initiates a conversation and has never enjoyed doing anything except lying in bed in the dark with the door closed. CNA #4 further stated the resident is never rude, complies with care most of the time, eats well and states he just wants to be alone. On 4/21/21 at approximately 3:20 p.m., CNA #1 was interviewed. CNA #1 stated Resident #1 requires little assistance with care, prefers to stay in his room in the dark, blinds and door closed, no television, peer interactions, reading, puzzles or other activity. CNA #1 stated the resident will sit up for meals for approximately 1 hour total with encouragement but as soon as the hour has passed he closes the door, turns off the light, closes the blinds and climbs back in bed. On 4/21/21 at approximately 3:30 p.m., an interview was conducted with the Speech Therapist who treats Resident #16. The Speech Therapist stated Resident #16 is usually in a dark room with the door closed, blinds drawn and in bed when she goes to him for treatment but he enjoys eating therefore he usually complies with her sessions but based on the rehabilitation meetings the resident isn't as motivated with physical and occupational therapy and the therapist feels he's capable of doing more than he does during their sessions. The Speech Therapist stated the lack of motivation is conveyed to the interdisciplinary team during meetings. On 4/21/21 at approximately 1:00 p.m., an interview was conducted with the spouse of Resident #16. The spouse stated for the past 9 years the resident hadn't wanted to do anything and she had exhausted her abilities to care for the resident; therefore alternative placement was being strongly considered. The spouse stated she believed the resident's mother suffered from depression. The spouse further stated the resident often complained of pain if he didn't want to do something and it was difficult getting the resident to see doctors or do anything therefore; the pain doctor had prescribed the psychoactive medications the resident was taking at home. The spouse stated prior to the resident's admission to the hospital the resident had become very weak and suffered complications from drinking water while lying in bed instead of sitting up to drink. On 4/22/21 at approximately 4:50 p.m., an interview was conducted with the Nurse Practitioner regarding Resident #16's social isolation, withdrawal, lack of interest, preference of darkness and lack of motivation. The Nurse Practitioner stated coordination of the psychological services didn't go as planned for the practice she is employed by had planned to bring a psychological Nurse Practitioner on board but it didn't happen and the day the other psychological Nurse Practitioner was in the facility there wasn't enough time for Resident #16 to be evaluated and treated but she would make more attempts to obtain services for the resident. The Nurse Practitioner stated he does need the services and she prefers not to prescribe or change psychoactive medications. On 4/22/21 at approximately 5:20 p.m., the above information was shared with the Administrator, DON, ADON and the [NAME] president of Nursing. The DON stated Resident # 16 psychological services would be coordinated and a practitioner would see him soon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy. The facility staff failed to assist one resident Resident #5 in the survey sample of 24 residents with making arrangements for dental services. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease, Ataxia, hypertension, acute peptic ulcer, type II diabetes, mental disorder due to known physiological condition, anxiety disorder, vascular dementia with behavioral disturbance, insomnia, and abnormal weight loss. The facility staff failed to provide Resident #5 with dental services. A Quarterly Minimum Data Set, dated [DATE] assessed this resident in the area of Cognitive Impairment (Brief Interview of Mental Status) BIMS as a (0). In the area of Activities of Daily Living this resident was assessed in the area of eating as a (1-1) requiring set up help only. In the area of Pain Management this resident was assessed as receiving PRN (as needed pain medication. In the area of Oral/Dental this area was not coded. A Care Plan dated 4/22/21 indicated: Has no natural teeth or tooth fragments - Resident complains of mouth or facial pain. Discomfort or difficulty with chewing. A 4/22/21 Nutritional Plan indicated: Dental pain, discomfort difficulty chewing- swallow disorder- difficulty or pain swallowing. Diet Order: indicated: Mechanical soft, LCS, NAS, fortified foods if on Fluid Restriction. A review of Nursing Notes dated 4/4/21 indicated: 9: PM -Tramadol given for mouth pain. Complaining of remaining teeth hurting. Nursing Notes dated 4/2/21 indicated: 3:46 A.M. Resident- up so far through this shift complain of teeth, mouth hurting pain, and unable to sleep. Clearly stating wants to go to the dentist. Resident does have many discolored teeth and fragments present in her mouth. Pain medication given. MD made aware. Will have the oncoming shift make daughter aware as well. Speech Therapy Note dated 12/23/20 at 4:58 P.M. indicated: Resident #5's diet was changed on 12/23/20 from a regular diet to a puree/mech due to a choking incident with regular meats during the afternoon meal. Heimlich maneuver and finger sweeps required to clear oral cavity. During an interview on 4/22/21 at 9:25 A.M. with the social worker, she was asked had a dental appointment been made for Resident #5. The social worker stated, she does not make the appointments nursing makes the appointments. The social worker stated, she would get with the Director of Nursing (DON) and get back with me and let me know if a dental appointment has been made for Resident #5. Note- the social worker did not inform me during the survey of an appointment or the status of Resident #'S dental care. During an interview on 4/22/21 at 6:36 P.M. with the DON she stated Resident #5's daughter did not want her to go out on any appointments. When asked if staff had contacted the daughter regarding Resident #5's complaint of wanting to see a dentist due to mouth and teeth pain, the DON stated, the daughter did not want her to go out. When asked for documentation that the daughter had signed or requested Resident #5 not have dental services, none was presented during the survey. A review of the facility's Dental Service Policy indicated: The facility will assist residents, as necessary, in making appointments and arranging transportation to and from the dentist offices if services are not provided in the facility. Arrangements for dental care shall be made promptly within 3 days if a residents loses or damages his/her dentures. If a referral does not occur within 3 days the facility must provide documentation of what was done to ensure the resident could still eat and drink adequately while awaiting dent services and the extenuating circumstances that led to the delay. The facility staff failed to assist one resident in obtaining routine dental services.

Based on staff interviews, clinical record review and facility documentation the facility staff to develop one of 23 residents (Resident #34) comprehensive personal centered care plans in the survey sample. The facility staff failed to develop a person-centered care plan to include the following: *Atrial Fibrillation with the use of anticoagulation, *Psychosis and Major depressive disorder with the use of antipsychotic medication use. The findings included: Resident #34 was originally admitted to the nursing facility on 04/30/19. Diagnoses for Resident #34 included, but not limited to, Atrial Fibrillation, Unspecified Psychosis and Major Depressive Disorder. The current Minimum Data Set (MDS) a 14-Day PPS with an Assessment Reference Date (ARD) of 05/14/19 coded the resident with a 15 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The residents MDS was coded for the usage of antipsychotic and anticoagulation. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an antipsychotic and anticoagulation for 7 days. The review of Resident #34's Physician Order Sheet indicated the following anticoagulation order: Eliquis 5 mg one tablet two times daily starting on 04/30/19 for Atrial Fibrillation. The review of Resident #34's Physician Order Sheet indicated the following antipsychotic/psychosis order: Seroquel 300 mg one tablet by mouth daily at bedtime for psychosis and Abilify15 mg-give one tablet daily starting on 04/30/19 for psychosis and Major Depressive disorder The review of Resident #34's comprehensive care plan did not include a care plan for Atrial Fibrillation with the use of an anticoagulation medication and Major depression disorder and psychosis with use a psychoactive medication. An interview was conducted with the Director of Nursing (DON) on 05/31/19 at approximately 11:10 a.m. When asked who was responsible for the development and revision of the resident person-centered care plan, The DON replied, We all can but the Assistant Director of Nursing (ADON) is mainly responsible. The DON said there should have been an anticoagulation and psychoactive care plan because the resident was taking Eliquis, Seroquel and Ability. When asked what was the purpose of a having an accurate person-centered-care plan, the DON replied, It allows everyone to know what is going on with the resident and how to manage their care. She stated the care plan should be accurate according to the physician orders. An anticoagulation care plan was given to the surveyor that was created on 05/31/19, but only created after it was requested by the surveyor. The review of the anticoagulation care plan included but not limited to the following information: Resident is at risk for bleeding related to anticoagulant use: resident is on Eliquis. The goal: will not experience any negative outcomes from use of the anticoagulant medication. Some of the intervention/approaches to manage goal included to monitor for interaction with other ordered medications, administer medication as ordered, monitor for busing or bleeding after venipuncture and obtain lab work as ordered and report any abnormal findings to the physician. A psychoactive medication care plan was given to the surveyor that was created on 05/31/19, but only created after it was requested by the surveyor. The review of the psychoactive care plan included but not limited to the following information: Resident will achieve desired effect from ordered medications and will experience no negative effects from medication use as ordered. Some of the intervention/approaches to manage goal included to observe and report signs/symptoms of tardive dyskinesia, Consulting Pharmacist Medication Regimen Review at least monthly, consult and coordinate care with mental health professional per physician order and targeted behaviors and side effects are being monitored. A pre-exit meeting was held with the [NAME] President of Operations Administrator, Director of Nurse Operation, Assistant Director of Nurse Operations, and Director of Nursing on 05/31/19 at approximately 3:05 p.m. The facility did not present any further information about the findings. The facility's policy: Person-Centered Baseline and Comprehensive Care Plan (Revision date: 05/17/18.) Goal/Objectives: -Reflect the outcome(s) desired/anticipated from the care, services, and support provided in response to the specific problems/concerns. Interventions/Approaches include but not limited to: -States what is to be done to assist the resident to achieve their outcomes. -Relates to the cause of the problem identified during assessment. -Monitor resident for compliance with care plan to include approaches. -The Director of Nursing/designee will be the coordinator of the care plan process. Comprehensive Care Plans: -Are oriented toward prevention and resident centered individualized care including his/her preference and goals. Definitions: *Atrial Fibrillation is the most common type of arrhythmia. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. (Source: www.Nhlbl.nih.gov) *Psychosis is a mental disorder characterized by a disconnection from reality. *Major depression disorder is a chronic (ongoing) type of depression in which a person's moods are regularly low (Mosby's Dictionary Medicine, Nursing & Health Professions 7th edition). *Eliquis is used help prevent strokes or blood clots in people who have Atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease (https://medlineplus.gov/ency/article/007365.htm). *Seroquel tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) (https://medlineplus.gov/ency/article/007365.htm). *Abilify is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain (https://medlineplus.gov/ency/article/007365.htm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and clinical record review, the facility staff failed to ensure 1 of 23 residents (Resident #27) in the survey sample who was unable to carry out activities of daily living, received the necessary services to maintain toenail care. The facility staff failed to provide podiatry services for Resident #27. The findings included: Resident #27 was originally admitted to the facility on [DATE]. The current diagnoses included: Hypotension, Major Depressive Disorder, Difficulty in walking and Type II Diabetes Mellitus. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/07/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as being a two person physical assist with transfers and one person physical assistance with dressing, eating, bathing and toileting. On 05/29/19 at approximately 1:16 PM, a lower extremity assessment was done by RN (Registered Nurse) #1 with the Resident's permission. Resident #27's 3rd and 4th toenails on his right foot were long and thick; they were hanging over his toes straight out. On 05/29/19 at 3:40 PM, an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #27's nurse, concerning the resident's toenails. She assessed his toenails and stated that she felt that he needed podiatry services. She also stated We do our skin checks or the CNA's will let us know. She stated, Then we notify the ADON (Assistant Director of Nursing) and they will notify the podiatrist. I just notified the charge nurse and she notified the ADON that Resident #27 need podiatry services. On 05/29/19 at approximately 3:46 PM, a review of the facility's podiatry book was made. Per the staff, Resident #27's name was just added to podiatry book. It was also confirmed by LPN #2 that he had not received podiatry services since his admission in October 2018. On 5/31/19 at approximately 9:30 AM the policy on foot care was received and included: Routine foot care should be provided as part of the resident's daily care. When indicated, a podiatrist should be consulted. The Purpose: To prevent infection. To prevent break in skin integrity of the feet. To promote peripheral circulation. To promote cleanliness. The Procedure: NOTES the following: Nail care for residents with thick mycotic nails or other problems should be provided by a licensed nurse or podiatrist. Residents with specific conditions including: IDDM (Insulin Dependent Diabetes Mellitus), PVD (Peripheral Vascular Disease) or long term anticoagulation therapy should have a podiatrist consult. The head/charge nurse should be notified of abnormal findings (corns, calluses, bunions, or breaks in the skin surface etc.) On 05/31/19, at approximately 3:05 PM, the above findings were shared with the Administrator, Director of Nursing and corporate consultant during the exit interview. The DON stated that the nurses and or nurses aides should have referred the resident for podiatry care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide respiratory services consistent with professional standards of care and the comprehensive person-centered care plan for one of 23 residents in the survey sample, Resident #22. For Resident #22, facility staff failed to administer oxygen at the correct liters per minute per order and comprehensive care plan. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, adult failure to thrive, vascular dementia, respiratory failure and osteoporosis. Resident #22's most recent MDS (minimum data set) assessment was an annual assessment with an ARD (Assessment Reference Date) of 4/24/19. Resident #22 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #22 was coded in section O (Special treatments, procedures, and programs) as receiving oxygen therapy. Review of Resident #22's May 2019 MAR (Medication Administration Record) revealed the following order: Oxygen at 2 L (liters)/minute per nasal cannula PRN (as needed). Resident #22's oxygen saturation care plan dated 4/25/18 documented the following: (Name of Resident) unable to maintain 02 saturation. Receives oxygen at 2 L (liters)/min PRN SOB (shortness of breath). Observations were made of Resident #22 on 5/30/19 at 9:33 a.m., 10:22 a.m., 2:30 p.m. and 3:11 p.m Her oxygen flow meter was set to 3 liters per minute instead of the ordered 2 liters. On 5/30/19 at 2:56 p.m., an interview was conducted with LPN (Licensed Practical Nurse), Resident #22's nurse that shift. When asked how she knew how many liters of oxygen a resident needed to be on, LPN #1 stated that she would look at physician's order to determine the liters of oxygen for that resident. LPN #1 stated that following the order was important because if a resident has COPD (chronic obstructive pulmonary disease) for instance; too much oxygen could drive up with C02 (carbon dioxide). When asked why Resident #22 was on oxygen, LPN #1 stated it was prn (as needed) for comfort but that she wanted to wear it all the time. When asked how many liters Resident #22 should be on; LPN #1 stated that her order was for 2 liters. When asked how often nurses check oxygen concentrator and flow meter, LPN #1 stated that she checked every day. LPN #1 stated that she had been in Resident #22's room that day but that she had so many residents on oxygen, she sometimes gets mixed up with how many liters they need to be on. LPN #1 followed this writer to Resident #22's room and at 3 p.m., LPN #1 confirmed that Resident #22 was on 3 liters. LPN #1 stated,It's reading at 3 liters. LPN #1 then adjusted Resident #22's oxygen flow meter to 2 liters. A few minutes later LPN #1 then changed her first initial observation and stated that the ball (ball used to adjust the flow of oxygen) was actually a little bit above the two line but that she had fixed it. When asked the purpose of the care plan, LPN #1 stated that the purpose of the care plan was to make sure the resident gets everything they need medically. LPN #1 stated that it was important for the care plan to be followed and accurate. When asked if Resident #22's care plan was being followed if her 02 was set at the wrong rate, LPN #1 stated that it was not followed. On 5/31/19 at 3:05 p.m., ASM (Administrative Staff Member) #1, the Administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled,Oxygen Administration documents in part, the following: .Procedure: Check physician's order to verify liter flow and method of administration.

Based on observation during the inspection of the medication room, staff interviews and the facility's policy review, the facility staff failed to ensure a Schedule II medication was secured in a permanent affixed locked cabinet. The facility staff failed to ensure a multi-dose vial of Morphine was secured in a permanently affixed locked medication cabinet. The findings included: On 05/30/19 at approximately 2:15 p.m., an inspection of the medication room was made with License Practical Nurse (LPN) #2. The facility only had one medication room. Located inside the medication room was a locked cabinet. The LPN unlocked the cabinet, which contained a large gray stat box. The surveyor asked the LPN, Can the stat box be removed from the cabinet she replied, Yes. The LPN removed the stat box from the cabinet then placed it back inside the cabinet then locked the cabinet back. The stat box was not permanently affixed inside the locked cabinet. The surveyor reviewed the content of the stat box. The stat box contained a one (1) multi-dose vial of Morphine 20 mg/ml oral solution (Roxanol); a Schedule II medication. On 05/31/19 at approximately 10:35 a.m., another inspection was made of the locked medication cabinet with LPN #1. The medication cabinet remained unchanged; the stat box was not permanently affixed. The stat box remained with the multi-dose vial of Morphine in it. On 05/31/19 at 11:35 a.m., an interview was conducted with the Assistant Director of Nurse Operations. She stated the stat box should have been permanently affixed because it contained a multi-dose vial of Morphine (Schedule II medication.) A pre-exit meeting was held with the [NAME] President of Operations, Administrator, Director of Nurse Operations, Assistant Director of Nurse Operations and the Director of Nursing on 05/31/19 at approximately 3:05 p.m. The surveyor asked if the stat box containing a multi-dose of Morphine (Schedule II medication), should be permanently affixed inside the medication cabinet. The Director of Nurse Operations replied, There should have been only a single dose vial of Morphine, basically I thought it was taken care of by our pharmacy. She said the pharmacy was contacted and they were out of the single doses of Morphine so a multi-dose vial was sent instead. She said the decision was made by the pharmacy and we were not aware of the multi-dose vial of Morphine inside the stat box. The surveyor asked, Since there was a multi-dose vial of Morphine located in the stat box, should the stat box containing the multi-dose vial Morphine be permanently affixed inside the medication cabinet? The [NAME] President of Operations stated, Yes, the box should have been permanently affixed. The facility's policy titled Virginia Health Services Pharmacy Services Policy (Revision date: 01/03/17). -Storage of drugs include but not limited to: The separately locked and permanently affixed compartments are provided for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control act of 1976 and other drugs subject to abuse. Definitions: *Morphine is used to relieve moderate to severe pain. Morphine extended-release tablets and capsules are only used to relieve severe (around-the-clock) pain that cannot be controlled by the use of other pain medications (https://medlineplus.gov/ency/article/007365.htm). *Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. www.DEA (Drug Enforcement Administration).gov.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to maintain a complete pain management program consistent with professional standards of practice and the comprehensive person centered care plan for two of 23 residents in the survey sample, Resident #6 and #22. 1. For Resident #6, facility staff failed to document the location of pain prior to administering pain medications on several occasions in May 2019. 2. For Resident #22, facility staff failed to document the location of pain prior to administering pain medication on two occasions in May of 2019. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, atrial fibrillation, high blood pressure, and adult failure to thrive. Resident #6's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/15/19. Resident #6 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #6 was coded in Section J (Pain Assessment Interview) as having frequent mild pain. Review of Resident #6's May 2019 POS (physician order summary) revealed the following order: Hydrocodone 5 mg (milligrams)-acetaminophen 325 mg tablet (1) (1 tab) TABLET oral As Needed Every Four Hours Starting 6/01/2017 .moderate pain. Review of Resident #6's May MAR (Medication Administration Record) revealed that she received the above medication 17 times in May. On the corresponding pain assessment on the MAR, location of pain was not documented for the following dates and times: 5/7/2019 at 3:30 a.m., 5/11/19 at 12:19 a.m., 5/11/19 at 9:55 p.m., 5/21/19 at 12:56 a.m., 5/22/19 at 8:52 a.m., 5/23/19 at 7:42 p.m., 5/25/19 at 4:10 a.m., 5/25/19 at 7:06 p.m., 5/27/19 at 4:11 p.m., 5/29/19 at 5:05 p.m., and 5/30/19 at 3:37 a.m. Review of Resident #6's May nursing notes failed to evidence location of pain for the above dates and times. Further review of Resident #6's nursing notes revealed that Resident #6 frequently had pain to her bilateral legs. Resident #6's pain management care plan dated 9/13/18 documented in part the following: Potential for pain due to BLE (bilateral lower extremity) contractures .Encourage (Name of Resident) to identify intensity, quality, and location of pain. On 5/31/19 at 9:58 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #6's nurse. When asked the process if a resident complains of pain, LPN #2 stated that she would go assess the pain, ask the location, intensity and have the resident rate the pain on a scale of 1-10 (10 being the worst possible pain). LPN #2 stated that for resident who cannot verbalize pain, she would look for non-verbal cues such as grimacing or guarding any part of the body. LPN #2 stated that she would attempt non-pharmacological pain interventions prior to administering pain medications and then she would administer pain medications, if non-[NAME] were ineffective. When asked if she would document her complete pain assessment, LPN #2 stated that she would. When asked where she would document the complete pain assessment, LPN #2 stated that the pain assessment was documented in a nursing note or on the MAR. When asked if location of pain was an important piece to the pain assessment, LPN #2 stated that it was and that location of pain should be documented. LPN #2 stated that the MAR did not give nurses the option to document location but that a nursing note should be written. When asked how she would know the location of Resident #6's pain on previous pain assessments, LPN #2 stated that being her nurse on a consistent basis, she knew that the resident frequently had pain in her legs. When asked if location should still be documented, LPN #2 stated that location should be documented in case she had a new area of pain. LPN #2 stated that it was important to document location of pain so that nursing can keep track of pain complaints. On 5/31/19 at 3:05 p.m., ASM (Administrative Staff Member) #1, the Administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Pain Management, documents in part, the following: .Assessments should include the onset, location, frequency, quality, and intensity of pain with the resident's self-report as the primary indicator of pain. No further information was presented prior to exit. (1) Hydrocodone 5 mg (milligrams)-acetaminophen 325 mg (NORCO)- narcotic analgesic used for the relief of moderate to moderately severe pain. This information was obtained from The National Institutes of Health. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=44b86290-2391-4b02-abd4-b1c0c611891e. 2. Resident #22 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, adult failure to thrive, vascular dementia, respiratory failure and osteoporosis. Resident #22's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (assessment reference date) of 4/24/19. Resident #22 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #22 was coded in in Section J (Pain Assessment Interview) as not having pain. Review of Resident #22's May 2019 POS (physician order summary) revealed the following order: Tylenol 325 mg (1) (milligrams) (650 mg) TABLET as Needed Every 6 Hours Starting 12/14/16 .for mild pain. Review of Resident #22's May 2019 MAR (Medication Administration Record) revealed that she received the above medication 4 times in May. On the corresponding pain assessment on the MAR, location of pain was not documented for the following dates and times: 5/18/19 at 4:32 p.m. and 5/19/19 at 1:00 p.m. Review of Resident #22's May nursing notes failed to evidence location of pain for the above dates and times. Resident #22's pain management care plan dated documented in part the following: Pain Management .Assess (Name of Resident #22) to determine if experiencing pain. If pain is present, conduct and document pain assessment particularly location, nature, intensity, and duration of pain. On 5/31/19 at 9:58 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, Resident #22's nurse. When asked the process if a resident complains of pain, LPN #2 stated that she would go assess the pain, ask the location, intensity and have the resident rate the pain on a scale of 1-10 (10 being the worst possible pain). LPN #2 stated that for resident who cannot verbalize pain, she would look for non-verbal cues such as grimacing or guarding any part of the body. LPN #2 stated that she would attempt non-pharmacological pain interventions prior to administering pain medications and then she would administer pain medications, if non-pharmacologicals were ineffective. When asked if she would document her complete pain assessment, LPN #2 stated that she would. When asked where she would document the complete pain assessment, LPN #2 stated that the pain assessment was documented in a nursing note or on the MAR. When asked if location of pain was an important piece to the pain assessment, LPN #2 stated that it was and that location of pain should be documented. LPN #2 stated that the MAR did not give nurses the option to document location but that a nursing note should be written. LPN #2 stated that it was important to document location of pain so that nursing can keep track of pain complaints. On 5/31/19 at 3:05 p.m., ASM (Administrative Staff Member) #1, the Administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. (1) Tylenol Tablet 325 mg (Acetaminophen)-Treats minor aches and pains and also reduces fever. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0008785/?report=details.