Based on resident and staff interview, record review and facility document review, the facility staff failed to promote resident self-determination through support of resident choice related to bathing for 1 of 28 current residents in the survey sample, resident # 41. The findings included: For resident # 41 (R41) the facility staff failed to provide three showers weekly per resident preference. R41's diagnoses included but were not limited to pneumonia, respiratory failure unspecified with hypoxia, hypertension, diabetes mellitus, chronic obstructive pulmonary disease and muscle weakness. The minimum data set (MDS) assessment for R41 with an assessment reference date of 12/31/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. On 3/24/25 at 7:00 PM during the initial tour this surveyor interviewed R41. The resident had a disheveled appearance and when asked about being assisted with baths and showers R41 stated, I'm supposed to get one three times a week but that hardly ever happens. It depends on the aide, I usually get one on Wednesdays but never know about the other days. Surveyor asked if lack of showers was related to low staffing and they stated, I think it's related to who is working. Some of them just don't want to do it. On 3/25/25 at 11:15 AM this surveyor asked the Administrator for bathing records for February and March for R41. The Administrator provided copies of daily assignment sheets for the days R41 was showered, but nothing from the clinical record. This surveyor asked if the documents provided were part of the clinical record, they stated they were not. This surveyor asked again for the bathing record in R41's clinical record and the Administrator stated, What's in the record isn't reflective of the care provided. Surveyor asked if the record should match the assignment sheets and they stated, Of course it should, but the showers are documented here. This resident wouldn't let us not give her a shower. She would definitely complain. According to the documents provided, R41 had a shower on 3/24/25. 03/25/25 at 01:54 PM this surveyor interviewed R41 again. Surveyor asked if they got a shower the night before on 3/24/25. They stated, I did, I'm sure it was because you were in here and we had talked about it. I'm used to taking a shower every day and I know that isn't possible here, but I have asked if they could at least do it three times a week and they said they could. Surveyor asked how often they are showered, I would say I do usually get one at least twice a week, but not always. On 3/25/25 at 2:15 PM this surveyor asked the Director of Nursing (DON) for the bathing records for February and March out of R41's clinical record and they were promptly provided. The assignment sheets for February were compared with the clinical record for February. According to the documentation, R41 was showered at least two times weekly and three times weekly for three of the 4 weeks. For March the documentation was compared. R4 was documented as having had one shower for week one, three showers for week two, and one shower for week three documented. For the current week, week four, resident was documented a shower on 3/24/25. The care plan for R41 was reviewed. There was a problem statement that read in part, ADLs (activities of daily living) Functional Status/Rehabilitation Potential Resident has made personal preferences known, and an approach for that problem statement that read, Allow choice of bath if desired. The Physician's orders were reviewed. An order with a start date of 12/24/24 read, Shower Days Monday/Wednesday/Saturday Evenings. The policy entitled, Resident Bath/Showering/Scheduling Policy with a revision date of 9/9/22. The document read in part, Residents will be bathed or showered according to their preferences in order to maintain healthly hygiene and skin condition . (A) Each resident will be asked about his/her bathing preferences upon admission (type of bathc, preferred days and times). On 3/26/25 at 4:00 PM the survey team met with the Administrator, DON, and Regional Director of Clinical services (RDCS), this concern was discussed at that time. No further information was provided to the survey team prior to the exit conference. 3/27/25 at 10:23 AM this surveyor met with the DON and informed them I was still looking for evidence that 3 showers/week were provided in March for R41. Explained that the resident told me that depending on who works she usually gets the Wednesday showers, but the other days she never knows if she will get one or not, and frequently not. Reviewed the dates that evidence had already been provided which indicated only one shower was given the first week of March and the third week of March. 03/27/25 04:00 PM the survey team met with the Administrator, DON, RDCS and Administrator in Training. The DON brought shower sheets for R41 and stated here are more for the time period you said you were focused on. Included sheets for 3/3 which had already been provided,3/5, 3/7, 3/14, 3/17 and 3/19. This surveyor asked why these shower sheets were not provided with the others on 3/25/25, they stated, The unit manager gave them to me today, I went back and asked her if she had anything else to show the showers were done and she gave me those. This surveyor informed those present that the resident repeatedly stated that three showers a week are not being given they would like them to know that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility staff failed to ensure a Durable Do Not Resuscitate (DDNR) form was signed by the ordering medical provider for one (1) of 28 sampled current residents (Resident #73). The findings include: Resident #73's DDNR order form was not signed by the ordering medical provider. Resident #73's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/7/25, was signed as completed on 1/9/25. Resident #73 was assessed as able to make self understood and as able to understand others. Resident #73's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. Resident #73's clinical record included a DDNR order form dated as completed on 1/16/25. This form included the following information: Physician's Order . I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. This form was not signed by a medical provider. On 3/25/25, The Administrator provided the surveyor with a copy of Resident #73's DDNR form, dated 1/16/25, which now included a medical provider signature. The Administrator reported the medical provider had emailed the signed DDNR order on 3/25/25. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to ensure Resident #73's medical provider had signed the DDNR form was discussed.

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the provider and the resident's responsible party of a change in condition for 1 of 28 current residents in the survey sample, resident # 66. The findings included: For resident #66 (R66), the facility staff failed to notify the provider or the responsible party (RP) of a significant weight loss. R66's diagnoses included but were not limited to, Alzheimer's disease with late onset, other seizures, dysphagia unspecified, other secondary Parkinsonism, other frontotemporal neurocognitive disorder and muscle weakness. R66's face sheet listed a sibling as the emergency contact as well as the responsible party. The minimum data set with an assessment reference date of 12/19/24 indicated that resident has severely impaired decision making and impaired short- and long-term memory. The comprehensive care plan included a focus for nutritional status that read, Resident has increased nutrition/hydration risk r/t (related to) mechanically altered textures. There was an approach dated 3/19/25 that read, Supplements as ordered. On 03/25/25 03:00 PM during a review of the weight record this surveyor noted a significant weight loss. R66 weighed 157.6 lbs. on 2/5/25 and on 03/11/2025, the resident weighed 144.4 pounds. This is a 8.38 % Loss in a month. The progress notes were reviewed. A note dated 3/18/25 read, New orders per RD consult: Administer Mighty Shake (a nutritional supplement drink) 2 times per day. RP aware. On 3/27/25 09:47 AM this surveyor interviewed the wound nurse who put in the above order. When asked where or how the order originated, they stated, The RD sends his recommendations by email, and we get them approved and put in the orders. When asked if they know why the RD recommended the Mighty Shakes, they stated they did not. When asked if they were aware that R66 had a weight loss, they stated they were not aware. The nurse stated they did get the order approved by the provider but would not have informed them the recommendation was due to weight loss as they did not know. They stated they did notify the RP of the new order but not the weight loss. This surveyor reviewed the policy entitled, Resident Change in Condition Policy. The document read in part, 5. They Physician/Provider and Resident/Family/Responsible Party will be notified when there has been .f. Significant weight loss of 5% in 30 days, 10% in 180 days. On 3/26/25 at 4:00 PM the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services and the Administrator in Training. This concern was reviewed with them at that time and during a pre-exit meeting on 3/27/25 at 4:00 PM. No further information was provided to the team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an accurate MDS assessment for 1 of 28 sampled residents (Resident #12). The findings include: For Resident #12, the facility staff failed to code the resident as having an indwelling catheter on the minimum data set (MDS) assessment dated [DATE]. Resident #12's diagnosis list indicated diagnoses, which included, but not limited to, Congestive Heart Failure, Vascular Dementia, Hypertension, Chronic Kidney Disease-Stage 3, Chronic Respiratory Failure with Hypoxia, Neuromuscular Dysfunction of Bladder, Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Anxiety Disorder, and Depression. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/6/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognitive abilities. Surveyor observed Resident #12 on 3/25/25 at 9:50 AM in bed with a catheter present and urine drainage tubing/bag hanging off the left side of resident's bed. A review of the medical provider orders revealed an order for Foley Catheter. A review of the February 2025 MAR (medication administration record) revealed resident received daily foley care from 2/6/25 through 2/28/25. A review of the resident's census revealed resident was hospitalized from [DATE], through February 6, 2025. A progress note dated 2/6/25 read in part, .Resident has Foley (catheter) in place . A review of the MDS dated [DATE] Section H (Bladder and Bowel) H0100. Appliances was not coded to reflect and indwelling catheter. A review of the comprehensive person-centered care plan read in part, .Indwelling Catheter .foley catheter care every shift . On 3/26/25 at 1:54 PM, surveyor interviewed licensed practical nurse #9 (LPN#9) and she reviewed the 2/13/25 MDS with surveyor. LPN#9 could not find any evidence the resident did not have a catheter. Surveyor also interviewed licensed practical nurse #1 (LPN#1) and she stated she thought Resident #12's catheter had been discontinued for a voiding trial. LPN#1 looked for evidence of a voiding trial with surveyor and stated she needed more time to look for evidence the catheter had been discontinued or for evidence the resident was on a voiding trial. LPN #9 retuned to surveyor and informed surveyor no evidence of a voiding trial could be located, and she agreed the MDS had been coded incorrectly. This concern was discussed on 3/26/25 at 4:00 PM at the end of day meeting with the administrator, director of nursing, administrator in training, and regional director of clinical services. A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 with a revision date of 10/2024, read in part, [page H-1] .It is important to know what appliances are in use .[page H-2] .Steps for Assessment .1. Examine the resident to note the presence of any urinary .appliances .2. Review the medical record, including bladder .records, for documentation of current .use of urinary .appliances .Coding Instructions .Check next to each appliance that was used at any time in the past 7 (seven) days . No further information regarding this concern was presented to the survey team prior to the exit conference on 3/27/25.

2. The facility staff failed to ensure Resident #73's Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability form was completed according to document guidance. Resident #73's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/7/25, was signed as completed on 1/9/25. Resident #73 was assessed as able to make self understood and as able to understand others. Resident #73's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. Resident #73's preadmission screening document, dated 12/31/24, included two (2) sections which required sub-questions in the section to be answered prior to completing the main question of the sections. - Section 2 DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? was answered No without the individual completing this form answering questions 2a, 2b, and 2c. - Section 4 DOES THE INDIVIDUAL HAVE A RELATED CONDITION? was answered No without the individual completing this form answering questions 4a, 4b, 4c, and 4d. On 3/27/25 at 12:15 p.m., the surveyor interviewed the facility's Social Worker via telephone. The Social Worker reported when the answer to the aforementioned unanswered questions is 'no' that she does not mark 'no.' The Social Worker stated she would have marked 'yes' if that had been the appropriate response. The Social Worker reported she was comfortable with the answers that was documented for the main question of Section 2 and the main question of Section 4. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to complete all questions of Resident #73's preadmission screening document was discussed. 3. The facility staff failed to ensure Resident #94's Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability form was completed according to document guidance. Resident #94's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/14/25, was signed as completed on 3/18/25. Resident #94 was assessed as rarely/never able to make self understood and as rarely/never able to understand others. Resident #94 was documented as having problems with long-term memory and as having problems with short-term memory. Resident #94's preadmission screening document, dated 1/4/24, included two (2) sections which required sub-questions in the section to be answered prior to completing the main question of the sections. - Section 2 DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? was answered No without the individual completing this form answering questions 2a, 2b, and 2c. - Section 4 DOES THE INDIVIDUAL HAVE A RELATED CONDITION? was answered No without the individual completing this form answering questions 4a, 4b, 4c, and 4d. On 3/27/25 at 12:15 p.m., the surveyor interviewed the facility's Social Worker via telephone. The Social Worker reported when the answer to the aforementioned unanswered questions is 'no' that she does not mark 'no.' The Social Worker stated she would have marked 'yes' if that had been the appropriate response. The Social Worker reported she was comfortable with the answer that was documented for the main question of Section 2 and the main question of Section 4. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to complete all questions of Resident #94's preadmission screening document was discussed. Based on staff interview. record review and facility document review, the facility staff failed to ensure a Level I PASRR (Preadmission screening and resident review) was completed for 3 of 28 current residents in the survey sample, residents # 66, #73, and $94. The findings included: 1. For resident #66 (R66) the facility staff failed to accurately complete the Level I PASRR before including it in the medical record. R66's diagnoses included, Alzheimer's disease, late onset, seizure disorder, frontotemperal neurocognitive disorder, major depressive disorder, anxiety disorder and unspecified mood disorder. A document entitled, Screening For Mental Illness, Retardation/Intellectual Disability, Or Related Condition was located in the clinical record. Question 5 was for whether or not R66 required a secondary, or level II assessment was blank. On 3/25/25 at 4:00 PM the survey team met with the Director of Nursing, Administrator and Administrator in training. This concern was discussed at that time. On 3/26/25 at 9:20 AM this surveyor was provided with the policy entitled, Social Services Policy with a revision date of 2/24/25 that read in part, B. Social Services will assist in implementing interventions for the resident's needs by developing and maintaining care plans which are individualized, realistic, with measurable goals, including, but not limited to; 1. Code Status, 2. Discharge planning, 3. Smoking ability, 4. Current and/or history of mood/behavior, cognitive and/or psychosocial issues, 5. Leave of absence, 6. Trauma, PTSD, 7. Cultural Preferences, 8. PASRR level II information and, 9. Substance abuse issues. There was no Level II in the record. This concern was reviewed with the Administrator, Director of Nursing, and Regional Director of Clinical Services again on 3/27/25 at 4:00 PM. The Director of Nursing stated that the the Level I Screening had been corrected and R66 did not require a Level II. No further information was provided to the survey team prior to the exit conference.

Based on resident interviews, staff interviews, and clinical record review, the facility staff failed to provide adequate supervision and/or monitoring in response to an accident/incident for one (1) of 28 sampled current residents (Resident #5). The findings include: The facility staff failed to ensure an assessment was completed and/or documented for Resident #5 after an event involving a handrail coming out of the bathroom wall. Review of Resident #5's clinical documentation failed to include information related to an event reported by Resident #5; this event was described as the handrail came out of the wall when the resident reported she was attempting to stand from the toilet. Resident #5's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/20/25, was signed as completed on 2/23/25. Resident #5 was assessed as able to make self understood and as usually able to understand others. Resident #5's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. On the afternoon of 3/26/25, Resident #5 reported she had fallen from the toilet when the handrail had detached from the wall when she was attempting to stand from the toilet. Resident #5 reported the fall resulted in her having a decreased ability to use her right leg and left arm. Resident #5 was unable to provide the date of the alleged fall. Resident #5 reported the facility's maintenance staff would be able to provide the date. Interviews with the Director of Maintenance, on 3/26/25 and 3/27/25, indicated the event happened on either 6/17/24 or 6/18/24. The Director of Maintenance could not confirm a fall. The Director of Maintenance reported the resident had already exited the bathroom prior to him entering the bathroom. Review of Resident #5's activities of daily living (ADL) documentation, for June 2024 and July 2024, showed the resident had not experienced a decline in ADL abilities. Resident #5's MDS assessment, with an ARD of 6/24/24, did not identify: (a) a decline in the resident's ADL activities and/or (b) a fall since the previous MDS assessment. On 3/26/25 at 4:02 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Administrator in Training (AIT), and Regional Director of Clinical Services. During this meeting, Resident #5's report of falling due to the handrail in her bathroom coming loose was discussed. The Administrator reported the resident did not fall when the handrail came loose. On 3/27/25 at 8:52 a.m., Licensed Practical Nurse (LPN) #8 reported she was not present when the handrail came out of the wall. LPN #8 stated the event occurred prior to her coming in for her work shift. LPN #8 reported that her understanding was the resident did not fall but sat back down on the toilet when the handrail dislodged from the wall. On 3/27/25 at 10:13 a.m., the Administrator confirmed the event involving Resident #5, when the handrail came free from the wall in the resident's bathroom, had not been documented in the resident's clinical record. The following information was found as part of a facility document titled Incident/Accident Policy (with a revision date of 10/1/24): - An incident/accident is any occurrence which is not consistent with the routine care of a particular resident. An incident/accident can occur anywhere and be discovered by anyone (resident, visitor, employee or volunteer). All incident/accidents involving residents will be analyzed and reported. - The incident/accident will be recorded in the electronic health record. The report will be completed as soon as possible after the occurrence but no later than by the end of the shift on which it occurred. - Documentation/assessment post-incident will be completed, including neurological assessment when indicted [sic]. Further assessments will be conducted as ordered by the provider or as indicated by nursing judgement. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to have evidence of assessing Resident #5 after the aforementioned incident/accident was discussed.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the medical provider orders for 1 of 28 sampled residents (Resident #175). The findings include: For Resident #175, the facility staff failed to administer supplemental oxygen at the rate ordered by the medical provider. Resident #175's diagnosis list indicated diagnoses that included, but were not limited to, Senile degeneration of brain, Insomnia, Hypertension, Pain, Restlessness and agitation, and Anxiety disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of, 3/21/25 coded the resident in Section C (Cognitive Patterns), as being severely impaired in decision-making with short and long-term memory problems. On 3/24/25 at 7:21 PM, surveyor observed Resident #175 in bed receiving oxygen via nasal cannula at the delivery rate of 2.0 l/m (two liters per minute) per the oxygen concentrator setting. On 3/25/25 at 9:15 AM, surveyor again observed Resident #175 in bed receiving oxygen via nasal cannula at the delivery rate of 2.0 l/m per the oxygen concentrator setting. Resident #175's current medical provider orders included an order for Oxygen at 3.0 (three) l/m via nasal cannula continuously with special instructions to check concentrator to ensure functioning and appropriate setting every shift. A review of the March 2025 MAR (medication administration record) revealed the oxygen concentrator had been checked to ensure appropriate setting on day shift and night shift on 3/24/25 and on day shift on 3/25/25. On 3/25/25 at 12:05 PM, surveyor again observed Resident #175 in bed receiving oxygen via nasal cannula at the delivery rate of 2.0 l/m per the oxygen concentrator setting. Surveyor spoke with registered nurse #2 (RN#2) and inquired how much oxygen Resident #175 was on and she stated three liters. RN#2 accompanied surveyor to the resident's room and agreed the oxygen concentrator was set on two liters. Surveyor asked RN#2 the process for verifying oxygen is on the proper setting and she stated she tries to check it when she is in the room. RN#2 agreed the oxygen should be on three liters and she set the flow meter to the correct flow rate of 3.0 m/l on the oxygen concentrator. This concern was discussed on 3/25/25 at 5:00 PM at the end of day meeting with the administrator, director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, Oxygen Administration (all routes) Policy with a revision date of 7/30/24 that read in part, .licensed clinicians with demonstrated competence will administer oxygen .as ordered by the provider .For oxygen concentrator .set flow meter to correct flow rate . No further information regarding this concern was presented to the survey team prior to exit on 3/27/25.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist and failed to provide evidence of medical provider review of a drug regimen review with recommendations for 1 of 28 sampled residents (Resident #42). The findings included: For Resident #42, the facility staff failed to ensure the resident's drug regimen was reviewed during January 2025 and facility staff were unable to provide evidence of medical provider review of the July 2024 drug regimen review. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Obstructive and Reflux Uropathy, Anxiety Disorder and Major Depressive Disorder. The recent minimum data set (MDS) with an assessment reference date (ARD) of 2/02/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #42's comprehensive person-centered care plan included a focus area stating the resident was at risk for adverse effects related to psychoactive medication use with an intervention for pharmacy review per routine. Resident #42's clinical record included a 7/29/24 pharmacy progress note indicating a drug regimen review was completed with recommendations. Surveyor was unable to locate the recommendation in the resident's clinical record. Surveyor reviewed Resident #42's clinical record and was unable to locate evidence of a January 2025 drug regimen review. On 3/26/25 at 4:03 PM, surveyor met with the Administrator, Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) and requested the July 2024 and January 2025 drug regimen reviews for Resident #42. On 3/27/25 at 10:15 AM, the DON provided a copy of a drug regimen review for Resident #42 dated 7/29/24 and stated the report was not in the resident's chart but the Atorvastatin was addressed. The 7/29/24 drug regimen review had not been signed by the medical provider. This drug regimen review read in part . (Issued on 7/29/2024) ***CLINICAL PRIORITY RECOMMENDATION: PROMPT RESPONSE REQUESTED. *** [Resident #42] receives daptomycin and statin therapy with Atorvastin Calcium concomitantly, which may be associated with myopathy and rhabdomyolysis. Recommendation: Please consider temporarily discontinuing Atorvastatin Calcium during daptomycin therapy A review of Resident #42's clinical record revealed the daptomycin ended on 8/03/24 as scheduled and the Atorvastin was discontinued on 8/13/24. On 3/27/25 at 10:15 AM, the DON also provided a Consultation Summary Report for January 2025 which included all residents who had a drug regimen review completed. Reviews were completed between 1/24/25 and 1/27/25. Resident #42 was not listed on this report indicating no drug regimen review was completed. Surveyor requested and received the facility policy titled Medication Regimen Review with a revision date of 6/01/24 which read in part .8. The consultant pharmacist will provide the resident's MRRs [medication regimen reviews] to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations . No further information regarding this concern was presented to the survey team prior to the exit conference on 3/27/25.

Based on clinical record review and facility document review, the facility staff failed to ensure residents are free of significant medication errors for 2 of 28 sampled residents (Resident #69 and Resident #77). The findings included: 1. For Resident #69, the facility staff failed to administer the medication Novolin as ordered by the provider. Resident #69's diagnosis list indicated diagnoses, which included, but not limited to Weakness, Atherosclerotic Heart Disease of Native Coronary Artery, Type 2 Diabetes Mellitus, Acute Respiratory Disease, Polyneuropathy, Chronic Kidney Disease-Stage 4, and Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/28/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Resident #69's current provider orders included the following insulin order: Novolin R FlexPen (insulin regular human) 100 unit/mL (milliliters) (3 mL) amount 6 units subcutaneous (applied under the skin); Hold for BG (blood glucose) <150 (less than one-hundred-fifty) Before Meals 8:00 AM, 12:00 PM, and 4:00 PM. A review of Resident #69's January 2025 and February 2025 MARs (medication administration records) indicated Novolin was administered on the following dates with BS (blood sugars) outside of the ordered parameter of holding if BS <150: 1/29/25-BS 123 2/9/25-BS 142 2/20/25-BS 137 2/26/25-BS-132 Resident #69's current comprehensive person-centered care plan included a focus area stating the resident had a diagnosis of Type 2 Diabetes with an intervention to administer medications as ordered. This concern was discussed on 3/26/25 at 4:00 PM at the end of day meeting with the administrator, director of nursing, administrator in training, and regional director of clinical services. Surveyor requested and received a facility policy titled, Medication Administration through Certain Routes of Administration that read in part, .ensures that medications are administered according to .physician orders .Subcutaneous injections .Procedure .2. Verify Medication Order on EMAR/MAR (electronic medication administration record/medication administration record); Check against physician order . No further information regarding this concern was presented to the survey team prior to the exit conference on 3/27/25. 2. For Resident #77, the facility staff failed to administer the medications Lantus, Humalog, and Insulin Glargine as ordered by the provider. Resident #77's diagnosis list indicated diagnoses, which included, but not limited to Hypothyroidism, Hyperlipidemia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder with Severe Psychotic Features, Vascular Dementia, Parkinson's disease without Dyskinesia, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Respiratory Failure with Hypoxia, and Chronic Kidney Disease-Stage 3. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/10/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Resident #77's current provider orders included the following insulin orders: Humalog 100 unit/mL-amt (amount) 16 units: subcutaneous Special instructions: Hold if less <175, Three Times a Day. Insulin glargine: 100 Unit/mL (3mL): amt: 54 units; subcutaneous Special instructions: hold if BS <150, Twice a Day. Resident #77 also had a previous order from the provider for Lantus Solostar 100 unit/mL (3mL); amt; 36 units; subcutaneous Special instructions: hold if BS <150 with an end date of 1/27/25. A review of Resident #77's January 2025 MAR indicated Lantus was administered on the following dates with BS (blood sugars) outside of the ordered parameter of holding if BS <150: 1/18/25 BS 102 1/23/25 BS 130 A review of the January, February, and March 2025 MARs indicated Humalog was administered on the following dates with BS outside of the ordered parameter of holding if BS <175: January 2025 1/4/25 BS-171 1/15/25 BS-169 1/17/25 BS-168 1/22/25 BS-140 1/25/25 BS-173 February 2025 2/1/25 BS-147 March 2025 3/9/25 BS 141 3/19/25 BS 173 3/22/25 BS 156 A review of the February and March 2025 MARs indicated Insulin Glargine was administered on the following dates with BS outside of the ordered parameter of holding if BS <150: 2/1/25 BS 147 3/9/25 BS 141 Resident #77's current comprehensive person-centered care plan included a focus area stating the resident is at risk for hypo/hyperglycemia related to diabetes with an intervention to administer medications as ordered. This concern was discussed on 3/26/25 at 4:00 PM at the end of day meeting with the administrator, director of nursing, administrator in training, and regional director of clinical services. Surveyor requested and received a facility policy titled, Medication Administration through Certain Routes of Administration that read in part, .ensures that medications are administered according to .physician orders .Subcutaneous injections .Procedure .2. Verify Medication Order on EMAR/MAR (electronic medication administration record/medication administration record); Check against physician order . No further information regarding this concern was presented to the survey team prior to the exit conference on 3/27/25.

3. The facility staff failed to ensure Resident #94's clinical record included the correct information related to documents sent with the resident to the local emergency department. Resident #94's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/14/25, was signed as completed on 3/18/25. Resident #94 was assessed as rarely/never able to make self understood and as rarely/never able to understand others. Resident #94 was documented as having problems with long-term memory and as having problems with short-term memory. Resident #94's clinical record included the following information as part of a nursing progress note dated 1/31/25 at 2:01 p.m.: . All paperwork sent including face sheet, copy of DNR/Advanced Directive, order summary, transfer sheet, care plan . This note documented activities and information related to Resident #94 being transferred to the emergency department. Resident #94 was ordered to be a full code. Resident #94 did not have a DNR (do not resuscitate) order. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to maintain a complete and/or accurate clinical record for Resident #94 was discussed. 4. Resident #68's clinical documentation included an incorrect weight documented on 2/11/25. Observations and interviews indicated the 2/11/25 weight was incorrect. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/5/25, was signed as completed on 2/9/25. Resident #68 was assessed as able to make self understood and as usually able to understand others. Resident #68's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. On 2/11/25, Resident #68's weight was documented at 168.1 pounds. This was approximately 97 pounds less than the resident's weight documented for the prior month. No documentation was found to indicate this documented change in weight had been addressed by the facility's staff. On 3/25/25 at 5:02 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS). During this meeting, Resident #68's weight being incorrectly documented was discussed. The DON reported Resident #68's weight should have been corrected and/or the resident reweighed. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to maintain a complete and/or accurate clinical record for Resident #68 was discussed. 2. For Resident #4, the facility staff failed to document the residents bath/showers in the clinical record. Resident #4's face sheet included the diagnoses spastic hemiplegia, cerebrovascular disease, convulsions, and anxiety disorder. Section C (cognitive patterns) of Resident #4's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/16/25 included a brief interview for mental status (BIMS) score of 15. Per the MDS manual a score of 15=cognitively intact. Section GG (functional abilities) was coded with a 1 for shower/bathe self to indicate this resident was dependent on staff in this area. Resident #4's comprehensive care plan included the problem area activities of daily living (ADL) functional status. Approaches included allow choice of bath if desired and bathing/hygiene with assist of one. On 03/25/25 at 8:35 a.m., Resident #4 stated they had not had a shower in a week. A review of Resident #4's point of care history for ADL care revealed that the facility staff had documented that this resident received a shower on 03/05/25 and complete bed baths on 03/05/25, 03/10/25, and on 03/11/25. On 03/25/25, the facility staff provided the surveyor with copies of documents identified as shower sheets. A review of these sheets indicated Resident #4 had a shower on 03/15/25, 03/19/25 and on 03/22/25. After providing the survey team with these documents the Administrator stated what was in the clinical record was not reflective of the care provided. On 03/25/25 at 5:00 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services and Director of Nursing the issue with the documentation regarding this resident's bathing not being part of the clinical record was reviewed. On 03/26/25 at 9:40 a.m., this Resident stated they had received a bath last night and had their sheets changed. No further information regarding this issue was provided to the survey team prior to the exit conference. Based on observation, staff interview and clinical record review the facility staff failed to ensure a complete an accurate clinical record for 4 of 28 residents, Resident #38, Resident #4, Resident #68 and Resident #94. The findings included: 1. For Resident #38 the facility staff failed to discontinue physician's orders related to intravenous access. Resident #38's face sheet listed diagnoses which included but not limited to chronic kidney disease, dehydration, and vomiting. Resident #38's most recent minimum data set with an assessment reference date of 02/05/25 assigned the resident a brief interview for mental status score of 10 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #38's comprehensive care plan was reviewed and contained a plan for Infection: UTI (urinary tract infection), Hx (history) IV (intravenous) access right FA (forearm). Resident #38's clinical record was reviewed and contained a physician's order summary for March 2025 which read in part, 1 L (liter) NS (normal saline) IV @ 100 ml/hr. Special Instructions: x 1L. Start Date: 03/20/2025. End Date: 03/21/2025 (DC [discontinue] Date), Peripheral IV: Change IV administration set every 4 days for continuous infusions. Start Date: 03/20/2025. End Date: 03/25/2025 (DC Date), and Peripheral IV: Change IV site/dressing as needed. Start Date: 03/20/2025. End Date: 03/25/2025 (DC Date). Resident #38's electronic medication administration record (eMAR) for the month of March 2025 was reviewed and contained entries as above. The entry for change IV administration set was initialed as completed on 03/24/25. Resident #38's nurse's progress notes were reviewed and contained notes which read in part, 03/23/2025 16:44 residents IV dislodged from right arm, cath piece intact, dry dressing placed ., 03/25/2025 12:38 Clarification note: NP (nurse practitioner) was notified that IV was dislodged on 03/23/25. NP gave order okay to not reinsert at that time ., and 03/25/2025 13:01 Clarification note related to peripheral IV documentation on 03/25/2025, resident does not have an IV inserted at this time. NP is aware of the IV site being removed and documentation occurring by this nurse on 3/24/2025. This nurse meant to put a progress not in for clarification during the shift. MD/RP aware. Surveyor spoke with licensed practical nurse (LPN) #12 on 03/25/25 at 12:30 pm regarding Resident #38's IV access. LPN #12 stated that resident no longer had IV access. Surveyor spoke with the director of nursing (DON) on 03/26/25 at regarding documentation of Resident #38's IV access. DON stated that the orders should have been discontinued when the IV access was removed. The concern of not discontinuing IV orders was discussed with the administrator, administrator-in-training, DON, and regional director of clinical services on 03/26/25 at 4:00 pm. No further information was provided prior to exit.

3. The facility staff failed to ensure that Resident #94's indwelling urinary catheter and/or drainage collection bag was positioned in a manner to decrease the risk for the development of infections. Resident #94's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/14/25, was signed as completed on 3/18/25. Resident #94 was assessed as rarely/never able to make self understood and as rarely/never able to understand others. Resident #94 was documented as having problems with long-term memory and as having problems with short-term memory. On 3/25/25 at 11:55 a.m., the surveyor noted the drainage tube (from the urine collection bag connected to the indwelling urinary catheter) was in contact with the floor beside the resident's bed. On 3/25/25 at 3:20 p.m., the surveyor noted the drainage tube (from the urine collection bag connected to the indwelling urinary catheter) continued to be in contact with the floor beside the resident's bed. On 3/25/25 at 4:55 p.m., the surveyor noted the drainage tube (from the urine collection bag connected to the indwelling urinary catheter) was in contact with the floor beside the resident's bed. The surveyor asked LPN (licensed practical nurse) #2 to check the placement of the urine collection bag. LPN #2 stated the urine collection bag had come out of its protective bag; LPN #2 stated she would change the drainage/collection bag. On 3/27/25 at 3:57 p.m., the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to prevent Resident #94's urine collection bag's drainage tube from coming into contact with the floor was discussed. Based on observation, staff interviews, clinical record reviews, and facility document reviews, the facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 28 current sampled residents (Resident #90, #15, #94, and #26). The findings were: 1. For Resident #90, facility staff failed to appropriately clean and disinfect a blood glucometer. Resident #90's face sheet listed diagnoses which included but were not limited to, Type 2 diabetes mellitus without complications. Resident #90's clinical record contained a provider order for Isolation/Transmission-Based Precautions: Droplet Precautions/Isolation with a start date of 03/23/25 and an end date of 03/30/25. On 03/25/25 at approximately 8:40 a.m. during a medication pass, the surveyor observed licensed practical nurse (LPN #3) take a clear plastic bag with the Resident #90's name written on it, out of the medication cart drawer. The bag contained a glucometer, and the nurse took the bag with its contents into the resident's room. LPN #3 laid the bag in a chair beside the resident's bed and removed the glucometer and laid the glucometer on the arm of the chair. The nurse obtained Resident #90's blood glucose. After administering the resident's medications, the nurse put the glucometer in the bag, put the bag in her scrubs' pocket while doffing personal protective equipment while verbally reporting she should not place the bag in her pocket but had nowhere to put it. LPN #3 took the bag outside of the room and placed it on top of the medication cart before putting the bag in the medication cart's drawer with other similar bags. LPN #3 then removed the bag and placed it back on top of the medication cart, removed the glucometer and wiped it with an alcohol swab before putting the glucometer back in the bag when it had dried. LPN #3 wiped the bag with and alcohol swab and placed the bag back in the medication cart's drawer. The surveyor asked LPN#3 if alcohol was the appropriate cleansing agent and the nurse replied, yes. There was no container of wipes noted on the medication cart and when asked whether the facility used wipes, the nurse did not comment and opened the medication cart's bottom drawer. There was no container of wipes or any wipes at all noted in the bottom drawer. The facility's glucometer policy and manufacturer's directions for use was provided on 03/25/25 at approximately 11:45 a.m. The clinical infection prevention document provided was named, Glucometer/Point of Care Blood Testing and Disinfection Procedure with an effective date of 10/15/2015 and last revision date of 12/27/2023. The policy read in part, . Whether shared or assigned to a singular resident, blood testing meters will be disinfected between each use (before use-the clinician should assume the meter is dirty and disinfect before use) according to manufacturer instructions and infection prevention guidelines Procedure: 2. Wipe meter using friction with recommended type of germicidal disinfectant wipe. 3. Maintain visible wetness of meter for required kill time according to the germicidal disinfectant instructions. Use multiple wipes if necessary. Do not reuse wipes. 6. Following specific testing processes outlined in manufacturer guidance: . Place glucometer on clean surface or place a barrier on surface that glucometer is placed/rests on Perform hand hygiene again and don clean gloves . The Assure Prism blood glucose monitoring system User Instruction Manual read on page 41, Only wipes with EPA registration numbers listed in the previous tables have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device. These EPA registration numbers can be found on the EPA website. On page 44, a caution box read in part, Please note only Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe [sic] have been tested with the Assure Prism multi meter at the time of printing this manual. Contact the manufacturer or distributor for the recent updates. On 03/25/25 at 5:00 p.m. during an end of day meeting, the administrator, director of nursing (DON), and regional director of clinical services (RDCS) was informed of the glucometer/infection control observation of LPN #3. On 03/26/25 at 1:40 p.m. the DON who was also the infection preventionist (IP) was interviewed and asked to describe her expectations for glucometer care and disinfection. I would not expect glucometers to be cleaned with alcohol. They (alcohol swabs) don't encompass every germ. The DON/IP reported she'd expect staff to follow manufacturer's directions for use. The DON/IP stated she would expect the medication cart to be wiped down after lying things on top of the cart, especially with an isolation room. The DON reported she had spoken with LPN #3 and the nurse told the DON she did use alcohol to wipe the glucometer. The DON informed the surveyor the facility does have wipes; the purple, orange, and white top containers which were all approved for use with the glucometers. No further information was provided prior to the exit conference. 4. For Resident #26, the facility staff failed to identify a resident was on droplet precautions prior to entering an isolation room and failed to follow their policy regarding donning personal protective equipment prior to entering a room of a resident on droplet precautions. Resident #26 had tested positive for Flu A. Resident #26's face sheet included the diagnoses mild cognitive impairment, dysphagia, hydrocephalus, and severe intellectual disabilities. Section C (cognitive patterns) of Resident #26's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/01/25 was coded 1/1/3 to indicate this resident had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #26's comprehensive care plan included the problem area infection Flu A. Approaches included Droplet/Contact precautions as ordered start date 03/19/25. Resident #26's clinical record included a progress note dated 03/18/25 indicating Resident #26 had tested positive for Flu A and a laboratory report indicating the positive Flu A results were reported to Registered Nurse (RN) #1 on 03/18/25 at 4:43 p.m. The provider ordered the following: Tamiflu (oseltamivir) 75 mg 1 capsule twice a day to begin on 03/19/25 at 4:00 p.m. this medication ended on 03/23/25 at 4:00 p.m. Isolation/Transmission based precautions combined droplet/contact precautions/isolation related to Flu A positive. The start date was documented as 03/19/25 end date was documented as open ended. These precautions were discontinued on 03/25/25. The facility staff provided the survey team with a copy of their policy titled, Infection Prevention and Control Program Policy last revision date 02/19/24 that read in part, It is our policy to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections . The facility staff also provided the survey team with a copy of a document titled, Guidance in Managing Respiratory Illnesses & Outbreaks. This document read in part, Outbreak Management .Notify all departments and re-educate all on hand hygiene, standard, and contact precautions. Use TBP [transmission based precautions] signage on residents room doors . On 03/24/25 at approximately 7:20 p.m., during initial tour of the facility the surveyor observed personal protective equipment (PPE) on the resident's door and signage outside this residents room that read: Stop, droplet-contact precautions. Perform hand hygiene before entering and when exiting. Respirator/mask before entering room. Discard and replace when exiting. Gown before entering room. Discard when exiting. Gloves before entering room. Discard when exiting. Eye protection before entering room. Discard or disinfect when exiting. After observing the PPE and signage the surveyor observed RN #1 inside the room without the required PPE. Upon exiting the room RN #1 was asked if anyone in the room was on precautions. RN #1 stated she had just taken the medication cart/hall, and she was not told that in report from the off going nurse. The surveyor approached RN #1 a few minutes later after this observation/interview and asked who they were administering medications to in this room. RN #1 stated they were administering medications to Resident #26's roommate. This Resident was not on precautions. This did require RN #1 to walk by Resident #26's bed to get to the other side of the room. On 03/24/25 at 7:25 p.m., Licensed Practical nurse (LPN) #2 stated Resident #26's Tamiflu had ended. A review of Resident #26's MAR's revealed that LPN #2 had signed for Resident #26's isolation on the MAR for 03/24/25 for day shift. RN #1 had not previously signed this MAR for the residents precautions/isolation. The facility staff provided the surveyor with a form titled; in-service attendance sign-in sheet dated 03/24/25 and signed by RN #1. Inservice topic was documented as when a resident finishes Tamiflu it does not indicate the isolation period is over. Flu patients are to be on isolation for 7 days. On 03/26/25 at 4:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Administrator in Training, and Regional Director of Clinical Services the DON/Infection Preventionist was asked their expectations about a staff entering a room of a resident that was FLU positive. The DON stated the nurse should have put on PPE for the resident on precautions. When asked the expectations of the off going nurse regarding reporting a positive flu case to the oncoming nurse. The DON stated she would have expected the off going nurse to let the oncoming nurse know about the precautions. On 03/27/25 at 9:50 a.m., during a phone interview with RN #1 this nurse was asked how she had clarified that Resident #26 was on droplet precautions. RN #1 stated the nurse she had received report from LPN #2 was still in the building and she spoke with them. LPN #2 had mistakenly thought the resident had finished their Tamiflu sooner than they had and thought the droplet precautions had ended. On 03/27/25 at 3:55 p.m., during a meeting with the Administrator, DON, Administrator in Training, and Regional Director of Clinical Services. The DON confirmed the facility had 8 active flu cases when the survey team entered the building on 03/24/25 and as of 03/27/25 had 14 active cases of the flu. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #15 the facility staff failed to follow infection control procedures for the cleaning of a glucometer. Resident #15's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus. Resident #15's most recent minimum data set with assessment reference date of 02/20/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #15's clinical record was reviewed and contained a physician's order summary which read in part Insulin lispro insulin pen; 100 units/ml; amt: 8 units; Subcutaneous. Task to record: Before: BS (blood sugar) . and Isolation/Transmission-based precautions: Combined Droplet/Contact Precautions/Isolation related to: FLU A POSITIVE. Start Date: 03/24/2025. Surveyor observed licensed practical nurse (LPN) # 12 on 03/25/25 at 1:30 pm checking Resident #15's blood sugar. LPN #12 retrieved resident's glucometer from the medication cart, donned PPE (personal protective equipment) prior to entering resident's room, checked resident's blood sugar, removed PPE, performed hand hygiene, and exited resident's room. Upon exiting room, LPN #12 placed the glucometer on top of the medication cart, retrieved a cleaning wipe from the cart, cleaned the glucometer with wipe, placed glucometer back onto the medication cart to dry then returned glucometer to storage bag and placed back into the cart. Surveyor did not observe LPN #12 clean the top of the medication cart after placing glucometer on it. Surveyor spoke with the facility infection preventionist (IP) on 03/26/25 at 12:50 pm regarding glucometer/medication cart cleaning. IP stated that it would be their expectation that LPN #12 clean the top of the medication cart after placing glucometer on it. The concern on not cleaning top of medication cart after placing contaminated glucometer on it was discussed with the administrator, administrator-in-training, director of nursing, and regional director of clinical services on 03/26/25 at 4:00 pm. No further information was provided prior to exit.

Based on interviews, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure a resident's medical provider and/or responsible party (RP) was notified of the inability to carry out a medical provider order for one (1) of 26 sampled residents, Resident #103. For Resident #103, the facility staff failed to notify the resident's medical provider and/or responsible party of the inability to carry out a medical provider's order for intravenous (IV) fluids. The findings include: Resident #103's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 9/2/20, was dated as completed on 9/8/20. Resident #103 was assessed as being able to make self understood and as being able to understand others. Resident #103's Brief Interview for Mental Status (BIMS) summary score was documented as a seven (7) out of 15; this indicated severe cognitive impairment. Resident #103 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #103's diagnoses included, but were not limited to: high blood pressure, pneumonia, dementia, heart disease, and lung disease. Resident #103's medical provider orders included an order dated 9/17/20 for one (1) bag of Normal Saline (an IV fluid) to be provided at 50mL per hour. Resident #103's nursing notes included an entry, dated 9/17/20 at 11:14 a.m., which documented a medical provider had given an order for one (1) bag of Normal Saline (an IV fluid) to be administered at 50mL per hour. Resident #103's clinical documentation did not include evidence the aforementioned medical provider ordered IV fluids had been administered. On 8/24/22 at 8:13 a.m., the Director of Nursing (DON) was asked about the administration of Resident #103's medical provider ordered IV fluids. The DON reported they did not see evidence of the IV fluids being administered. On 8/24/22 at 10:39 a.m., the Assistant Director of Nursing (ADON) reported they spoke with the nurses (Registered Nurse (RN) #21 and RN #22) who was providing care for Resident #103 when the medical provider gave the order for the IV fluids. The ADON stated, RN #21 reported that RN #22 made two (2) attempts to obtain IV access on Resident #103; both attempts were unsuccessful. The ADON reported RN #22 was unable to remember details about Resident #103. The ADON stated someone should have notified the medical provider that their IV order for Resident #103 was unable to be followed. The following information was found in a facility policy titled Resident Change in Condition Policy (with a revision date of 7/2/21): - The Resident / Physician or Provider / Family / Responsible Party will be notified when there has been: . A need to alter the resident's medical treatment, including a change in provider orders . - The nurse will record the information related to the change in condition and subsequent events and notifications in the resident's health record. On 8/24/22 at 4:34 p.m., a team meeting was held with the facility's Interim Administrator, DON, and Regional Director of Clinical Services (RDCS). The failure of the facility staff to notify Resident #103's medical provider and responsible party of the inability to provide the aforementioned ordered IV fluids was discussed. On 8/25/22 at 11:45 a.m., a team meeting was held with the facility's Interim Administrator, DON, and RDCS. The DON and the RDCS reported Resident #103's medical provider and responsible party should have been notified when facility staff members were unable to administer the ordered IV fluids. This is a complaint deficiency.

Based on Resident interview, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 of 21 current Resident reviews, Resident #37. Resident #37's care plan included the intervention monitor the thrill and bruit. Resident #37 had a permacath in the right subclavian area. A Permacath insertion is the placement of a special IV line into the blood vessel in your neck or upper chest just under the collarbone. The findings included: Resident #37's diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. Section C (cognitive patterns) of Resident #37's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/22/22 included a brief interview for mental status (BIMS) summary score of 12 out of a possible 15 points. Section O (special treatments, procedures, and programs) was coded to indicate Resident #37 received dialysis. The residents comprehensive care plan included the focus area receives dialysis treatments 3 times weekly end stage renal disease (ESRD). Interventions included, but were not limited to, monitor thrill and bruit. 08/23/22 1:20 p.m., Licensed Practical Nurse (LPN) #2 stated Resident # 37's access for dialysis was located in their right upper chest. 08/23/22 3:30 p.m., Resident #37 confirmed their dialysis port was in her right upper chest. 08/23/22 2:02 p.m., LPN #3 stated they would review the care plan. 08/23/22 2:14 p.m., LPN #4, (MDS/care plan nurse) stated this was their first dialysis patient. 08/23/22 4:20 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services the issue regarding Resident #37's care plan was reviewed. 08/24/22, the DON provided the surveyor with a copy of an updated care plan and stated Resident #37 had a permacath. This care plan had been updated and the intervention to monitor the thrill and bruit was removed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint deficiency, the facility staff failed to follow a medical provider's orders for one (1) of 26 sampled residents, Resident #103. For Resident #103, the facility staff failed to follow medical provider orders for intravenous (IV) fluids. The findings included: Resident #103's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 9/2/20, was dated as completed on 9/8/20. Resident #103 was assessed as being able to make self understood and as being able to understand others. Resident #103's Brief Interview for Mental Status (BIMS) summary score was documented as a seven (7) out of 15; this indicated severe cognitive impairment. Resident #103 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #103's diagnoses included, but were not limited to: high blood pressure, pneumonia, dementia, heart disease, and lung disease. Resident #103's medical provider orders included an order dated 9/17/20 for one (1) bag of Normal Saline (an IV fluid) to be provided at 50mL per hour. Resident #103's nursing notes included an entry, dated 9/17/20 at 11:14 a.m., which documented a medical provider had given an order for one (1) bag of Normal Saline (an IV fluid) to be administered at 50mL per hour. Resident #103's clinical documentation did not include evidence the aforementioned medical provider ordered IV fluids had been administered. On 8/24/22 at 8:13 a.m., the Director of Nursing (DON) was asked about the administration of Resident #103's medical provider ordered IV fluids. The DON reported they did not see evidence of the IV fluids being administered. On 8/24/22 at 10:39 a.m., the Assistant Director of Nursing (ADON) reported they spoke with the nurses (Registered Nurse (RN) #21 and RN #22) who was providing care for Resident #103 when the medical provider gave the order for the IV fluids. The ADON stated, RN #21 reported that RN #22 made two (2) attempts to obtain IV access on Resident #103; both attempts were unsuccessful. The ADON reported RN #22 was unable to remember details about Resident #103. The ADON stated someone should have notified the medical provider that their IV order for Resident #103 were unable to be followed. On 8/24/22 at 4:34 p.m., a team meeting was held with the facility's Interim Administrator, DON, and Regional Director of Clinical Services. The failure of the facility staff to provide Resident #103's aforementioned medical provider ordered IV fluids was discussed. This is a complaint deficiency.

Based on interviews, clinical record reviews, and facility document review, the facility staff failed to ensure medical provider ordered laboratory tests were completed for one (1) of 21 sampled current residents, Resident #15. For Resident #15, the facility staff failed to obtain 'STAT' Keppra and carbamazepine levels. Resident #15 was prescribed Keppra and carbamazepine for the diagnosis of seizures. (STAT is a medical abbreviation meaning immediately or at once.) The findings include: Resident #15's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 5/29/22, was dated as completed on 6/2/22. Resident #15 was assessed as being able to make self understood and as being able to understand others. Resident #15's Brief Interview for Mental Status (BIMS) summary score was documented as a six (6) out of 15; this indicated severe cognitive impairment. Resident #15 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #15's diagnoses included, but were not limited to: dementia, traumatic brain injury, seizures, and depression. Resident #15's clinical record included a provider order, dated 7/29/22 at 3:08 p.m., for laboratory blood tests for Keppra and carbamazepine levels to be obtained STAT. Review of Resident #15's clinical record failed to include laboratory test results for the Keppra level and/or the carbamazepine level. Resident #15 was care planned for being at risk for falls with one of the contributing factors being documented as conversion disorder with seizures. One (1) of the interventions for the fall risk care plan was labs [sic] as ordered. contact md [sic] with any abnormal values. On 8/24/22 at 1:25 p.m., the Director of Nursing (DON) provided the survey team with a copy of a fax from the laboratory company. This fax was dated July 29, 2022 with the time of 7:33 p.m. This fax stated INCORRECT TUBE TYPE for one (1) of Resident #15's aforementioned laboratory test (the Keppra level). On 8/24/22 at 2:41 p.m., the Assistant Director of Nursing (ADON) reported they had called the laboratory prior to collecting the blood sample for the aforementioned laboratory tests; the laboratory staff told them to collect the blood in a red tube. The ADON reported the aforementioned fax from the laboratory company was found on their desk after the surveyor asked about the laboratory test results for Resident #15's Keppra and carbamazepine levels that were ordered on 7/29/22. The ADON reported they did not know when the facility received the fax. Review of the Facility's Lab Tracking Log for July 29, 2022 revealed that Resident #15's STAT laboratory orders for a Keppra level and a carbamazepine level were not entered in the log. On 8/24/22 at 3:00 p.m., the ADON confirmed the Keppra level and carbamazepine level laboratory tests had not been entered in the Lab Tracking Log; the ADON stated that STAT laboratory tests are not always entered in the Lab Tracking Log. On 8/24/22 at 3:40 p.m., the ADON provided to the surveyor with documentation indicating a medical provider was notified, on 8/24/22 at 11:30 a.m., of the failure of the facility staff to ensure Resident #15's 7/29/22 STAT orders for a Keppra level and a carbamazepine had been completed. The medical provider gave new orders to obtain the laboratory tests. On 8/24/22 at 4:34 p.m., a team meeting was held with the facility's Interim Administrator, DON, and Regional Director of Clinical Services (RDCS). The failure of the facility staff to obtain Resident #15's aforementioned medical provider ordered STAT laboratory blood test results was discussed.

2. A Permacath insertion is the placement of a special IV line into the blood vessel in your neck or upper chest just under the collarbone. An AV fistula is typically located in your arm, however, if necessary it can be placed in the leg. Resident #37's diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. Section C (cognitive patterns) of Resident #37's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/22/22 included a brief interview for mental status (BIMS) summary score of 12 out of a possible 15 points. Section O (special treatments, procedures, and programs) was coded to indicate Resident #37 received dialysis. The residents comprehensive care plan included the focus area receives dialysis treatments 3 times weekly end stage renal disease (ESRD). Resident #37's order summary report as of 08/23/22 included the following active orders: Check bruit and thrill every shift related to dependence on renal dialysis. Order date 07/06/22. Dialysis AV Shunt - Monitor every shift for signs and symptoms of bleeding. Order date 07/06/22. Resident #37's August medication administration records (MARs) included an order to check the bruit and thrill. The nursing staff had documented for the entire month of August that they were checking the bruit and thrill. At least 13 different nurses had signed the MAR as completing this task. Resident #37's August treatment administration sheets (TARs) included the order monitor dialysis AV shunt. The nursing staff had documented for the entire month of August that they were monitoring the AV shunt. At least 11 different nurses had signed this treatment sheet. 08/23/22 1:20 p.m., Licensed Practical Nurse (LPN) #2 stated Resident # 37's access for dialysis was located in their right upper chest. 08/23/22 1:50 p.m., LPN #2 stated the facility had batch orders for dialysis and the admitting person probably needed to uncheck what was not being used when putting the orders in the computer. 08/23/22 3:30 p.m., Resident #37 confirmed their dialysis port was in her right upper chest. 08/23/22 4:20 p.m., during an end of the day meeting the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services was made aware of the issue regarding Resident #37's clinical record. 08/24/22, the DON confirmed Resident #37 had a permacath and provided the surveyor with a copy of an updated order that read, perma cath, right subclavian-Monitor every shift for signs and symptoms of bleeding 08/25/22 12:43 p.m., the Regional Director of Clinical Services stated they did not have a policy on documentation regarding this issue. No further information regarding this issue was provided to the survey team prior to the exit conference. Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical records for two (2) of 26 sampled residents, Resident #37 and Resident #103. For Resident #103, the facility staff failed to document attempts to administer medical provider ordered intravenous (IV) fluids. For Resident #37, the facility nursing staff were documenting they were checking the bruit and thrill and monitoring the arteriovenous (AV) shunt every shift. Resident #37 had a permacath in their right subclavian area. The findings include: 1. The facility staff failed to document details related to attempts to administer medical provider ordered intravenous (IV) fluids for Resident #103. Resident #103's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 9/2/20, was dated as completed on 9/8/20. Resident #103 was assessed as being able to make self understood and as being able to understand others. Resident #103's Brief Interview for Mental Status (BIMS) summary score was documented as a seven (7) out of 15; this indicated severe cognitive impairment. Resident #103 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #103's diagnoses included, but were not limited to: high blood pressure, pneumonia, dementia, heart disease, and lung disease. Resident #103's medical provider orders included an order dated 9/17/20 for one (1) bag of Normal Saline (an IV fluid) to be administered at 50mL per hour. Resident #103's nursing notes included an entry, dated 9/17/20 at 11:14 a.m., which documented a medical provider had given an order for one (1) bag of Normal Saline (an IV fluid) to be administered at 50mL per hour. Resident #103's clinical documentation did not include evidence the aforementioned medical provider ordered IV fluids had been administered. On 8/24/22 at 8:13 a.m., the Director of Nursing (DON) was asked about the administration of Resident #103's medical provider ordered IV fluids. The DON reported they did not see evidence of the IV fluids being administered. On 8/24/22 at 10:39 a.m., the Assistant Director of Nursing (ADON) reported they spoke with the nurses (Registered Nurse (RN) #21 and RN #22) who were providing care for Resident #103 when the medical provider gave the orders for the IV fluids. The ADON stated, RN #21 reported that RN #22 made two (2) attempts to obtain IV access on Resident #103; both attempts were unsuccessful. The ADON reported RN #22 was unable to remember details about Resident #103. Neither of these attempts to obtain an IV access had been documented in the resident's clinical record. The following information was found in a facility policy titled Resident Change in Condition Policy (with a revision date of 7/2/21): - The Resident / Physician or Provider / Family / Responsible Party will be notified when there has been: . A need to alter the resident's medical treatment, including a change in provider orders . - The nurse will record the information related to the change in condition and subsequent events and notifications in the resident's health record. The following information was found in a policy titled General Dose Preparation and Medical Administration (with a revised date of 1/1/22): . After medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: . Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN (as needed) medications, application site) on appropriate forms . On 8/24/22 at 4:34 p.m., a team meeting was held with the facility's Interim Administrator, DON, and Regional Director of Clinical Services. The failure of the facility staff to document the attempts to obtain IV access, for Resident #103, was discussed.

Based on staff interviews, clinical record review, and facility document review, it was determined the facility staff failed to ensure that one (1) of 24 sampled residents (Resident #81) was free from a unnecessary psychotropic medication as evidence by the administration of a psychotropic medication (lorazepam) for a reason other than the reason ordered by the provider. The findings include: Resident #81 was administered a psychotropic medication (lorazepam) for a reason other than the provider documented reason the medication was ordered. Resident #81's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/27/19, had the resident's Brief Interview for Mental Status scored a three (3) out of 15. The resident was assessed as receiving anti-anxiety medications. Resident #81's diagnoses included, but were not limited to: high blood pressure, dementia, diabetes, seizures, and anxiety. Resident #81's care plan included, but was not limited to, focus areas of: anxiety, seizure disorder, and verbal behaviors. Resident #81's provider orders included a current order, dated 11/21/2019, for two (2) mg lorazepam to be administered via intramuscular injection every four (4) hours as needed for seizures. Resident #81's electronic medication administration records (eMAR) had documentation indicating the aforementioned ordered lorazepam was administered at the following times: on 12/31/2019 at 12:41 a.m. and 1/4/2020 at 12:10 a.m. A progress note, with an effective date and time of 12/31/19 at 12:41 a.m., documented Resident #81's condition as yelling about a man being in [Resident's] room, yelling about being put in the bed . This progress note was written related to the administration of the lorazepam; no documentation of seizure activity was found by or provided to the surveyor. A progress note, with an effective date and time of 1/4/20 at 12:10 a.m., documented Resident #81's condition as yelling, inconsolable . This progress note was written related to the administration of the lorazepam; no documentation of seizure activity was found by or provided to the surveyor. The following information was found in a pharmacy policy titled General Dose Preparation and Medication Administration (with an effective date of 12/1/07 and a revision date of 1/1/13): Document necessary medication administration/treatment information . on appropriate forms . The facility's Administrator provided this policy to the survey team on 3/2/20 at 3:58 p.m. Wording of this policy indicated the section quoted above applied to as needed medications (PRN medications). On 3/3/20 at 8:24 a.m., the facility's Administrator was asked about the administration of lorazepam to Resident #81 for a reason other than as ordered for seizures. The Administrator confirmed the lorazepam administrations in question failed to follow the provider's order. During a survey team meeting with the facility's Administrator and Director of Nursing, on 3/3/20 at 11:15 a.m., the aforementioned lorazepam administrations for Resident #81 was discussed for a final time.