**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident family member interview, and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 5 residents (Resident #5), in the survey sample. The findings included: Resident #5 was originally admitted to the facility 3/1/25 after an acute care hospital stay. The admission diagnoses included; cerebral infarction, type 2 diabetes mellitus with unspecified complications, unspecified congestive heart failure, and essential hypertension. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/7/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 02 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were severely impaired. On 3/5/25 at 10:10 AM during an observation tour for room [ROOM NUMBER], it was observed that there was large/deep gauges in the drywall behind the (A) bed headboard and the room light fixture cover was cracked. It was also observed that the floor between the (A) bed and the (B) bed had a large area that was black and very dirty. On 3/5/25 at 1:55 PM an interview was conducted with Family Member #1. Family Member #1 stated that Resident #5 was admitted to the facility over the weekend and the wall behind the headboard of the bed needs repair and the light fixture cover has a crack in the lens. Family Member #1 also stated that there is a large area on the floor between the residents beds that is very dirty and disgusting. Family Member #1further stated, this floor has looked like this all day, and no one should have to live like this. On 3/5/25 at 2:15 PM an interview was conducted with the Housekeeping Director. The Housekeeping Director stated that the floor in room [ROOM NUMBER] is not acceptable. The Housekeeping Director also stated, the housekeeper was probably going to come back and clean the floor however the facility only has (1) one housekeeper working today and she probably got busy doing something else. On 3/5/25 at 2:50 PM an interview was conducted with the Maintenance Director. The Maintenance Director stated, the wall behind the headboard and the light fixture in room [ROOM NUMBER] should not look like it does. He also stated, I will fix these issues as soon as I can. On 3/6/25 at approximately 4:22 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. 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 observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to administer significant medications on admission for 1 of 5 residents (Resident #3), a closed record resident, in the survey sample. The findings included: Resident #3 was originally admitted to the facility 12/31/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Malignant Neoplasm of Brain Unspecified and Convulsion Disorder. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/06/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated Resident #3 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with touch assistance with eating, Dependent with toileting hygiene, shower/bathe self, lower body dressing and personal hygiene. The Care Plan dated 1/01/25 read that the resident is at risk for complications related to Convulsive Disorder. The Goal is the resident will not have an adverse consequence due to their convulsive disorder. The interventions for Resident #3 Administer medication as ordered and notify MD as indicated. The Physician's Order Summary (POS) for December 2024 read: Keppra (levetiracetam) Oral Tablet 500 MG. Give 1 tablet by mouth every 12 hours for Progressive weakness. Order date: 12/31/2024. Dexamethasone Oral Tablet 4 MG. Give 1 tablet by mouth three times a day for Thrombocytopenia. Order date: 12/31/2024. The Medication Administration Record (MAR) for December 2024 read: Keppra oral Tablet 500 MG. Give 1 tablet by mouth every 12 hours (9:00 am and 9:00 pm) for Progressive weakness. Order date: 12/31/2024 at 5:28 PM. A review of the above MAR, for Resident #3 was coded as (5) meaning 5=Hold/See Nursing Progress Notes dated 12/31/24 at 8:52 p.m. A review of the admissions, progress and order note does not reveal the meaning of why the resident's Keppra or Dexamethasone was placed on hold. According to the Admissions note, Resident #3 arrived at the facility via stretcher on 12/31/24 at 5:06 PM. An interview was conducted on 3/05/25 at approximately 2:20 PM., with Licensed Practical Nurse (LPN) #1. LPN #1 said that the on-call physician was called on 12/31/24 to put the Keppra on hold because the medication wasn't available in the Omnicell (Medication Dispensing System). LPN #1 also said, If medications aren't in the Omnicell, a STAT order usually takes 4-6 hours. Typically medications are pulled from Omnicell or called in STAT which usually takes 4-6 hours if not in Omnicell. I would have called pharmacy. LPN #1 stated the resident was administered the Keppra the following day on 1/1/25. Keppra (levetiracetam) is used alone or together with other medicines to help control certain types of seizures (eg, partial-onset seizures, myoclonic seizures, or tonic-clonic seizures) in the treatment of epilepsy. This medicine cannot cure epilepsy and will only work to control seizures for as long as you continue to use it (https://www.mayoclinic.org/drugs-supplements/levetiracetam-oral-route/description/drg-20068010). Dexamethsone is used to provide relief for inflamed areas of the body. It is used to treat a number of different conditions, such as inflammation (swelling), severe allergies, adrenal problems, arthritis, asthma, blood or bone marrow problems, kidney problems, skin conditions, and flare-ups of multiple sclerosis (https://www.mayoclinic.org/drugs-supplements/dexamethasone-oral-route/description/drg-20075207). On 03/06/25 at approximately 4:25 PM., 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 observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure one Resident (Resident # 5) in a survey sample of 62 residents was clinically appropriate to self-administer medications. The findings included: 1. For Resident # 5, the facility staff allowed prescription eye drops to be kept at the bedside without an order and self administration assessment. On 6/5/2024 at 9:30 a.m., a plastic prescription bag with an affixed label that stated Bremonidine 0.2 % eye gtts (drops) was noted on Resident # 5's overbed table. The eye drops had been opened and still had medication remaining. Resident # 5 stated she kept the eye drops at her bedside because the staff members kept losing her eye drops. Resident # 5 stated that she was diagnosed with glaucoma and she was very concerned about not getting the eye drops on time. Resident # 5 stated she would give the eye drops to the nurses when it was time to administer them. On 6/5/2024 at 10:05 a.m., the bag with the eye drops was still on the overbed table. On 6/5/2024 at 10:20 a.m., the eye drops were still on the overbed table. On 6/5/2024 at 10:30 a.m., an interview was conducted in the conference room with the Director of Nursing and Corporate Nurse Consultant. Both stated that medications should not be kept at the bedside without the resident being assessed for self administration of medications. Both stated that medications should be kept on the medication cart until time for administration. Review of the clinical record revealed an order for Bremonidine 0.2 % eye gtts instill one drop in both eyes Brimonidine Tartrate Solution 0.2 %- Instill 1 drop in both eyes two times a day for glaucoma -Order Date 07/29/2022 1253 There was no documentation of eye drops being administered on 4/21/2024 at 9 a.m. and 4/30/2024 at 5 p.m. Review of the physicians orders revealed no orders for the medication to be left at the bedside. Review of the care plan revealed no documentation of self administration of medications or medications to be left at the bedside. During the end of day debriefing on 6/5/2024, the Administrator and Corporate Nurse Consultant were informed of the findings. They were asked about the risks of medications being left at the bedside. The Corporate Nurse Consultant stated there was a risk of other residents getting the medications and a risk of the resident administering the medication outside of the scheduled times as ordered by the physician. The Corporate Nurse Consultant stated if a resident had a self-administration clearance, the medication would be kept in a locked box at the bedside. They were asked to provide any information about eye drops not being administered by nurses due to the medication not being available. They stated they were unaware of nurses not having the eye drops available at the time of administration. Both stated medications should not be left at the bedside without an order and a self-administration assessment. On 6/6/2024 at 1:40 p.m., an interview was conducted with the Director of Nursing who stated the eye drops were removed from Resident # 5's bedside table and placed in the medication cart. The Director of Nursing stated the maintenance director located a locked box to use if a self administration assessment was done and deemed appropriate. The Director of Nursing stated that there was no assessment done at the time of the survey and interview. No further information was provided prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure one resident (Resident # 5) in the survey sample of 62 residents had the right to make choices about aspects of life in the facility. The Findings included: 1. For Resident # 5, the facility staff often failed to provide more coffee as requested. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. Review of the Physicians orders revealed an order for a Regular Diabetic Diet. There was no noted restriction on the number of cups of coffee consumed by Resident # 5. During the initial tour of the facility on 6/4/2024 at 11:42 a.m., Resident # 5 stated she enjoyed having more coffee after breakfast but it was hard to get another cup. Resident # 5 stated breakfast was served early at the facility. However, she liked more coffee after breakfast. On 6/5/2024 at 9:00 a.m., Resident # 5 stated she asked for coffee after breakfast. She stated Nobody brought another cup yet but it's probably all gone by now. The breakfast tray was gone and there was no coffee on Resident # 5's bedside table. A beverage cart was observed at the nurses station. There were 3 carafes of coffee, sugar, creamer and cups located on the cart. Nursing staff members were not observed in the hallways. On 6/5/2024 at 9:52 a.m., the Director of Nursing was observed walking in the hallway. She was asked if residents could get more coffee if they desired, to which she responded yes. The Director of Nursing stated the staff members could get more coffee from the Dietary department. The Director of Nursing looked around the hallway, then observed the beverage cart at the Nurses station and determined there was coffee in one of the carafes. One carafe was empty. The Director of Nursing poured two cups of coffee (one for Resident # 5 and the other for the roommate.) The Director of Nursing gave the two cups of coffee to LPN (Licensed Practical Nurse)-1 and asked her to give them to the two residents. LPN-1 was observed placing one cup of coffee on the overbed table for Resident # 5 and the other was given to the roommate. The surveyor asked if she received the coffee. Resident # 5 stated she received the coffee but could not pour it into her personal coffee cup with a lid located on the bedside table. CNA (Certified Nursing Assistant)-1 walked into the room while the surveyor was talking with the resident and poured the coffee into Resident # 5's personal coffee cup. CNA-1 stated Resident # 5 could not pour the coffee into her own personal cup so staff members had to provide assistance. Resident # 5 smiled and stated getting the extra coffee made her happy. She stated she was Glad there was some left. During the Group Interview on 6/5/2024 at 11:00 a.m., thirteen alert and oriented residents participated. Surveyor stated several residents complained of not being able to get extra coffee as desired. During the end of day debriefing, the Administrator and Corporate Nurse Consultant were informed of the findings. The Corporate Nurse stated residents should be able to have another cup of coffee without a long delay. No further information was provided prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to inform and provide written information to formulate an advance directive for 2 of 62 residents (Residents #3 and #21) in the survey sample. The findings included: 1. Resident #3 was originally admitted to the facility 5/2/24 after an acute hospital stay. The current diagnoses included metabolic encephalopathy, difficulty in walking, type 2 diabetes mellitus, muscle weakness, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/4/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. A review of Resident #3's clinical records didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, or autopsy request or other. On 6/5/24 at 5:30 PM an interview was conducted with the Admissions Director. The Admissions Director stated that the Advance Directive is received from the hospital chart and the resident is asked if further information regarding an Advance Directive is desired. The Admissions Director also stated that the resident will sign the Business Contract and has the opportunity to indicate if he or she would like more information regarding an Advance Directive. The admission Director also voiced that the facility has no Advance Directive for Residents #3. The admission Director further stated that Residents #3 does not have a Business Contract signed and this indicates that the opportunity to develop an Advance Directive was not provided. 2. Resident #21 was originally admitted to the facility on [DATE] after an acute hospital stay. The current diagnoses included hemiplegia and hemiparesis, muscle weakness, type 2 diabetes with hyperglycemia, and depression. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/9/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. A review of Resident #21's clinical records didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, or autopsy request or other. On 6/5/24 at 5:30 PM an interview was conducted with the Admissions Director. The Admissions Director stated that the Advance Directive is received from the hospital chart and the resident is asked if further information regarding an Advance Directive is desired. The Admissions Director also stated that the resident will sign the Business Contract and has the opportunity to indicate if he or she would like more information regarding an Advance Directive. The admission Director also voiced that the facility has no Advance Directive for Residents #21. The admission Director further stated that Residents #21 does not have a Business Contract signed and this indicates that the opportunity to develop an Advance Directive was not provided. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. 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 staff interviews and clinical record review, the facility staff failed to ensure a resident was free from misappropriation of personal property for 1 of 62 residents (Resident #173), in the survey sample. The findings included: Resident #173 was originally admitted to the facility 6/3/24 after an acute care hospital stay. The resident's diagnoses included alcohol abuse and glaucoma. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 6/3/24. The tool revealed at number 1. Cognitive state, that the resident was oriented to person and place. An interview was conducted with the resident on 6/10/24 at approximately 1:40 P.M. Resident #173 stated he had not received his eye drops since admission to the facility. The resident further stated that his sister administered his ophthalmic drops when he was home. The resident also stated he had not experienced blurred vision, burning, itching, or a feeling as if something was his eye since he was not being administered the ophthalmic drops. The resident asked, when would he receive the ophthalmic drops. Resident #173 had the following ophthalmic orders dated 6/3/24; Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % - Instill 1 drop in both eyes two times a day. The Medication administration Record (MAR) revealed on 6/6, 6/9 and 6/10 the 9:00 P. M., medication was documented as waiting for pharmacy and on order. During the 6/10/24, medication storage task of the Hall 3 medication cart, the Dorzolamide HCl-Timolol Mal ophthalmic drops were not on the medication cart. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 6/10/24 at approximately 1:07 PM. LPN #6 stated she administered the resident's Dorzolamide HCl-Timolol Mal ophthalmic drops that morning and she threw the bottle in the trash afterwards because they were drops sent over from the hospital. An interview was conducted with the Pharmacist on 6/10/24 at 2:30 PM. The Pharmacist stated the Dorzolamide HCl-Timolol Mal ophthalmic drops were delivered to the facility on 6/4/24 and signed as received by Registered Nurse (RN) #4. The location of the ophthalmic drops which were delivered and signed as delivered was not determined by the facility's staff. A nurse's note was also written for the medication on 6/12/24. It stated Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 %. Instill 1 drop in both eyes two times a day for one time hold order per the Physician's Assistant because the family was providing the supplies and the resident is his own Responsible Party. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator, and two Corporate Nurse Consultants. They had no new information regarding the missing bottle of Dorzolamide HCl-Timolol Mal ophthalmic drops.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive person-centered care plan for 2 (#'s 172 and 165) residents in a survey sample of 62 residents. The findings included: 1. For Resident # 172 the facility staff failed to provide a comprehensive care plan for wounds. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes, hypertension, on anticoagulant therapy, sustained injuries to left foot and leg in car accident. discharged from hospital with multiple wounds requiring sutures to the left leg as well as a lymphatic wound. On 5/1/24 the admitting nurse made the following entry: 5/1/24 at 12:00 AM - Skilled Nursing Focus: pt here for pt and ot he has a wound to the left leg no wound orders present at the moment. On 5/1/24 at 1:05 PM the wound specialist was in to see the Resident and he assessed all 4 wounds and identified 3 of them as lacerations that were sustained during the accident and sutured by the hospital. He put orders in for treatments to the affected areas. The wound doctor assessed and identified one wound as a lymphatic wound ulcer and prescribed treatment for that as well. A review of the comprehensive care plan revealed the following: FOCUS: SKIN IMPAIRMENT: the resident has a skin impairment Created on: 04/30/2024. GOAL: The skin impairment will heal without complications thru review date Created on: 04/30/2024. INTERVENTIONS: Notify MD as indicated Date Initiated: 04/30/2024. Observe area for signs of improvement or decline Date Initiated: 04/30/2024. Treatment as ordered Date Initiated: 04/30/2024 Created on: 04/30/2024. On 6/13/24 at approximately 12:30 PM an interview was conducted with LPN (Licensed Practical Nurse) 1 who stated that the purpose of a care plan is to direct the care of the Resident. When asked if a care plan says skin impairment is that enough information to tell you what the impairment, she stated that it was not. When asked if a care plan should be more specific, she stated that it should be Tailored to the individual needs of each resident. She further stated that it should specifically how to care for each resident, such as ADL(Activities of Daily Living) care, dietary, activities, code status, and plans for discharge. She stated that it should be updated as the needs of the resident change. A review of the care plan policy revealed the following excerpt: Policy: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing. On 6/13/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #165, the facility staff failed to derive a comprehensive care plan for multiple acquired pressure sores. Resident #165 was admitted to the facility on [DATE], and discharged on 4-20-21 (29 days later) with diagnoses including; Diabetes type 2, acute hip fracture with surgical repair, Foley urinary catheter placement after hip fracture, and congestive obstructive pulmonary disorder (COPD). Resident #165's most recent MDS (Minimum Data Set Assessment) was an admission assessment. The MDS coded Resident #165 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as alert and able to make needs known, with some confusion at times. The Resident was coded as frequently incontinent of bowel and a Foley catheter for bladder. The Resident was no longer in the facility and a closed record review was conducted. The Resident had no pressure wounds upon admission. Physician orders were reviewed and revealed that on 3-23-21 after admission the Resident was receiving an Allevyn cushion dressing to the sacrum from the hospital every day for protection, and skin prep wipes to heels every shift for protection prior to the development of the pressure sores. This indicated that the facility staff were aware of the risk potential for skin breakdown for Resident #165. No other preventive measures were put in place for the immobile Resident with a surgical repair for her fractured hip which increased the likelihood of skin impairment. Resident #165's Activity of daily living sheets documented the incontinence/hygiene, and bathing care provided for the Resident. Review of those documents revealed that during the month of April 2021 personal hygiene was not given for the following dates and shifts: On 4-9-21, and 4-14-21, (7am to 3pm) day shift staff documented extensive assistance from 1 staff member required by the Resident for personal hygiene care. No other day shifts were documented as hygiene care having been given on this 8 hour shift during the 20 day period (18 days missed) from 4-1-21 through discharge on [DATE]. On 4-1-21, 4-2-21, 4-4-21, 4-5-21, 4-13-21, 4-14-21, 4-16-21, and 4-19-21, (3pm to 11pm) evening shift staff documented total dependence from 1 staff member required by the Resident for personal hygiene care. No other evening shifts were documented as hygiene care having been given on this 8 hour shift during the 20 day period (12 evenings missed) from 4-1-21 through discharge on [DATE]. Bathing care was documented as being planned for Monday, Wednesday, Friday 7am to 3pm shift (day shift). Those baths did not occur on 4-2-21, 4-5-21, 4-12-21, and 4-19-21, and the Resident was documented as completely dependant on one staff member for bathing. Eight opportunities for baths were planned from 4-1-21 through 4-20-21, and only 4 were given. Review of Resident #165's physician and nursing progress notes revealed a Resident who was total care. The notes indicated that on 4-13-21 the Resident went out of the facility for an Orthopedic appointment and returned to the facility later in the afternoon. In the nursing progress notes, on 4-13-21 at 3:15 pm, the nurse documented that the Resident returned from her Orthopedic follow up appointment with new orders and that a dressing change was provided to the Resident's sacrum and heels, with some discomfort noted to sites. Will continue to monitor. Which indicated that nursing staff were aware of wounds. An interview was conducted with family which revealed that they were present when the pressure sores on the sacrum and heels were identified for the Resident at the Orthopedic appointment, and the information was communicated to the staff upon the Resident's return to the facility. This indicates that the unstageable pressure sore of the sacrum was known by the staff on 4-13-21, and a skin assessment was partially completed by nursing staff on that day which documented the unstageable sacral wound. Weekly skin Evaluation documents were reviewed and revealed that 4 existed in the clinical record. None were complete. Those were as follows: 1. 3-30-21 first weekly assessment skin intact without impairment. 2. 4-6-21 second weekly assessment skin intact without impairment. 3. 4-13-21 third weekly assessment site sacrum pressure 2.5 long, 2.0 wide unstageable, right heel pressure 2.2 long, 2.1 wide suspected deep tissue injury, left heel pressure 3.0 long, 2.5 wide suspected deep tissue injury. No further documentation nor description was given, and it is unknown if these measurements were centimeters or inches. 4. 4-20-21 fourth weekly assessment documented site left gluteal fold pressure, Sacrum pressure no measurements nor description noted, however, the Resident now had a new pressure ulcer added to the document on her left gluteal fold/ischium, and the bilateral heels were not mentioned. The pressure wound found to the right lateral leg was never mentioned. It is referred to later in this investigation. The physician progress notes and physician's order review further revealed that no orders nor indications that the facility doctor was ever made aware of the unstageable pressure sores on 4-13-21. Not until 4-16-21 (3 days later) did a progress note appear from the wound specialist practice. On 4-16-21 a wound Advanced Registered Nurse Practitioner (wound NP) completed an assessment and issued new orders after being made aware of the identification of the unstageable pressure sores identified on 4-13-21 at the Orthopedic doctor's appointment. The orders were as follows: Ordered 4-16-21- (7 items) 1. Prostat 30 milliliters (ml) two times per day supplement. 2. Use pillows and wedges to keep patient off of backside at all times to decrease pressure and aid in healing. 3. Prevalon boots to bilateral heels at all times except when performing morning care. 4. Right ischial ulcer clean with dermal wound cleaner, apply thin duoderm to area change Monday, Wednesday, Friday and as needed if it comes off, keep covered at all times. 5. Sacrum cleanse with dermal wound cleanser apply santyl nickel thick to gauze that is moistened with microcyn hydrogel cover with allevyn life sacral dressing change twice per day and as needed for incontinence episodes. 6. X-ray to sacral ulcer to assess bone condition. 7. Place on group 2 low air loss mattress for unstageable ulcer to sacrum and left ischium. Ordered 4-17-21- (1 item) 1. Left heel deep tissue injury skin prep every other day and cover with allevyn life heel foam to help aid in pressure reduction, Ordered 4-19-21- (1 item) 1. Right lateral leg cleanse with dermal wound cleanser apply iodosorb gel cover with allevyn life foam to help with pressure reduction change on Monday Wednesday Friday necrotic wound. It is notable to mention that the right gluteal/Ichium ulcer and right lateral leg ulcers were never mentioned on the weekly skin assessments, and no treatment for the left gluteal/Ichium ulcer was ever obtained. The Wound NP's progress note dated 4-16-21 at 2:48 pm, included the following: Ulcer to sacral region, wound to right lower extremity, wound to left ischium, skin discoloration (deep tissue injury)to bilateral heels, fall with hip fracture, nonambulatory, deconditioning, .medication currently taking . then listed those medications. The note went on to describe the wounds as follows: Open sacral pressure ulcer unstageable 6 cm long, 7.5 centimeters (cm) wide, 0.1 cm deep, no granulation tissue, 100% black necrotic (dead) tissue within the wound bed Open right ischial pressure ulcer unstageable 1.5 cm long, 1.8 cm wide, 0.1 cm deep, no granulation tissue, 100 % yellow necrotic (dead) tissue within the wound bed. Open right lateral leg 10 cm long, 2.0 cm wide, 0.1 cm deep, no granulation tissue, 100% black eschar/necrotic (dead) tissue within the wound bed DTI to (deep tissue injury) bilateral heels. The note continues to state that the Resident's daughter was called and made aware that the Resident may require plastic surgery at some point for the wounds. Resident #165's Treatment Administration Record (TAR) was reviewed and revealed that the physician's orders for wound care treatment were not completed for the following wounds, on the following dates, as listed below: Sacrum - Omitted on 4-11-21, 4-16-21, 4-19-21. Ischium - The order was placed on the TAR, however, never signed as administered. Right lateral Leg - The order was placed on the TAR, however, never signed as administered. Bilateral heels - Omitted on 4-5-21, 4-6-21, 4-11-21, 4-12-21. The facility policies for Skin Assessments, and Wound/Skin Assessments were reviewed and revealed the following: Skin Assessments; 1. A licensed nurse will ensure that a skin risk assessment using the Braden Scale is done upon admission, weekly for four weeks, and quarterly thereafter. 4. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 5. Notify provider with updates and/or changes to skin integrity. 6. Notify responsible party with updates and/or changes to skin integrity.Documented upon admission, weekly, and as needed if the Resident or wound condition deteriorates. Wound/Skin Assessments; 1. A licensed nurse will assess patients for any skin impairments, including surgical wounds, vascular wounds/ulcers, pressure ulcers/injuries, skin tears, etc 2. The skin observation tool will be completed by a licensed nurse at least every 7 days, detailing any wound/skin impairments These policy documents that were provided by the facility were accompanied by training materials from the facility's nursing practice standards (Mosby's and NCLEX) used to train nursing staff in the facility on wound care. The documents described current skin care preventative techniques, assessments, other prevention modalities, care planning, wound identification, measuring, and staging standards, treatment of wounds and required documentation of wounds. The following elements were notated in the training materials, and accepted as a standard of practice for a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location b. Stage of the wound if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness) c. Measurements: height, width, depth, undermining, tunneling d. Description of wound characteristics to include the following; i. Color of the wound bed ii. Type of tissue in the wound bed (i.e., granulation, slough, eschar/necrosis, epithelium) iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated) iiii. Presence, amount and characteristics of wound drainage/exudate v. Presence or absence of odor vi. Presence or absence of pain, and wound treatments are also to be documented at the time of each treatment. No Braden scale skin assessment was completed at the time of admission, nor ever during the entire course of the Resident's stay. The Resident had no pressure wounds upon admission. The Resident's care plan was reviewed and indicated the only care plan area mentioning skin was potential for skin impairment related to immobility, catheter. admitted with a non-removable dressing to her left hip. This entry described the fractured hip surgical wound dressing. The interventions were keep skin clean and dry, moisture barrier cream as needed for protection of skin, peri care with incontinence episodes, and weekly skin assessment. The Resident had a Foley catheter, so urinary incontinence was not a complicating factor in wound development. There was no care plan ever completed for the pressure ulcer wounds that developed on Resident #156's Sacrum, ischium, leg, and both heels. Multiple staff nurses were interviewed by surveyors on 2 shifts. Those interviews indicated that the nursing staff did not complete wound assessments as reported by all of those interviewed. The nurses stated that they contacted the contracted wound doctor's practice to come in and do the assessments. The nursing staff stated all skin assessments were in the computerized record, and they had no paper assessments. The wound physician was onsite during the survey, and was interviewed by surveyors. She stated that No one asked me to teach the nurses how to assess wounds, so I haven't done that. The Director of Nursing (DON) was asked what her expectation was for incontinence rounds and skin breakdown assessment. Her reply was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNA's (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. The nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent worsening. The Resident's unstageable pressure wounds were never identified by the facility. No measurements nor descriptions of the wounds were every placed in the clinical record by nursing staff. The 4-13-21 identification of multiple unstageable pressure wounds occurred at an outside orthopedics appointment and not treated until the Resident was seen by the wound NP on 4-16-21, 3 days after identification. Resident #165 was not afforded timely bathing, nor hygiene/incontinence care, multiple unstageable pressure sores were not identified by the facility, orders and treatments were delayed, and not administered as per physician's order. No care plan ever existed for the pressure ulcers after they were identified. On 6-7-24 during the end of day meeting the Administrator and Regional Nurse Consultant were made aware of the above findings. The Administrator stated that this happened before her tenure, and with a different owner. She stated she had no additional information to provide prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #359, the facility staff failed to revise the resident's care plan to include new interventions to meet goals after learning that the resident had a fall on 6/3/24 shortly after being admitted to the facility and learning that the resident was legally blind. Resident #359 was admitted to the facility on [DATE]. Diagnoses for Resident #359 included but were not limited to acute metabolic encephalopathy, urinary tract infection, end-stage renal disease, and legal blindness. Resident #359's Minimum Data Set (MDS) was not yet complete. An observation was made on 6/4/24 at approximately 1:30 PM of Resident #359 sitting on the side of the bed and the resident's call bell was on the floor under the bed. After asking the resident if he had any concerns, Resident #359 shared that he had slid to the floor shortly after being admitted the day before and his roommate had to call and get staff to help him back to bed. In review of Resident #359's clinical record, there was no documentation supporting his fall. After notifying the Administrator and Regional Nurse Consultant (RNC) #1 of what the resident shared and how there was no documentation of the event, they did an investigation on 6/6/24. Licensed Practical Nurse (LPN) #1, shared during the investigation that she forgot to document that the resident had a fall on her shift on 6/3/24. Resident #359's care plan was revised on 6/7/24 with no changes noted to prevent future falls. 3. For Resident #36, the facility staff failed to develop, review, and revise an Activities of Daily Living (ADLs) care plan. Resident #36 was admitted to the facility originally on 1/16/24 and re-admitted last on 5/7/24. Diagnoses for Resident # 36 included but were not limited to pressure ulcers, Diabetes Mellitus, Bilateral Lower Extremity Amputation, and Clostridium Difficile. Resident #36's Minimum Data Set (MDS) with an Assessment Reference Date of 5/7/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 which indicated that Resident #36 was cognitively intact. In section GG (Activities of Daily Living), the resident required partial assistance for eating and oral care, was dependent on toileting and bed mobility, and required substantial maximum assistance for dressing. On 6/4/24 an interview was conducted with Resident #36 and his private caretaker. Resident #36 shared that his wife got a private caretaker after he had fallen twice in the facility. The resident says he could not call for help because due to the neuropathy in his hands, he could not use the call bell. Resident #36 said he shared this information with the Administrator and Admissions Director the prior week, but no action had taken place. Resident #36 indicated the only ADL care he receives is primarily from occupational therapy and they are the only people who have giving him a bath. A review of the clinical record supports Resident #36 falling on 4/27/24 and 5/13/24. On 4/27/24 Resident #36 was sent to the emergency room for a dislodged percutaneous endoscopic gastrostomy (PEG) tube and on 5/13/24 the resident did not sustain any injuries. Resident #36 care plan did not include anything regarding ADL care. The above findings were shared with the Administrator, Corporate Nurse #1, and Corporate Nurse #2 on 6/13/2024 at approximately 11:45 AM. No further information was provided prior to the conclusion of the survey.4. For Resident #161 the facility staff failed to review and revise the care plan after the development of a stage 2 pressure area. On 6/6/24 a review of the clinical record revealed that Resident #161 was admitted to the facility on [DATE] from an acute care hospital, where he was admitted after sustaining facial injuries after a fall. The document entitled admission Skin Assessment lists only the facial injuries as skin impairments, no pressure ulcers or other wounds are listed. On 2/14/24 Resident #161 was evaluated by the wound doctor and the following excerpts are from the wound doctor's notes: Wound Evaluation Date: 02/14/2024, Location: Sacrum Measurements: Length: 8.50 cm, Width: 8.00 cm, L x W: 68.00 cm2, Depth: 0.20 cm Observations: Location: Sacrum, Etiology: Pressure, Stage/Severity: Stage 2, Acquired in House: Yes, Date Wound Acquired: 02/11/2024, Wound Status: New. On 6/6/24 a review of the care plan revealed the following for skin / wounds: FOCUS: The resident is at risk for pressure ulcers related to advanced age, chronic health conditions, dry fragile skin, immobility, inability to turn and reposition independently, incontinence Created on: 02/01/2024 Revision on: 05/14/2024. GOAL: the resident will not have a skin impairment thru the review period Created on: 02/01/2024 Revision on: 05/14/2024 INTERVENTION: Assess resident for risk of skin breakdown Date Initiated: 02/01/2024 Keep skin clean and dry as possible Date Initiated: 02/01/2024 Created on: 02/01/2024. Skin assessments as indicated Date Initiated: 02/01/2024 Created on: 02/01/2024. The care plan did not reflect the actual wound development nor the treatment or interventions to prevent further worsening of the wound. On 6/13/24 at approximately 12:30 PM an interview was conducted with LPN (Licensed Practical Nurse) 1 who stated that the purpose of a care plan is to direct the care of the Resident. When asked if a care plan says skin impairment is that enough information to tell you what the impairment, she stated that it was not. When asked if a care plan should be more specific, she stated that it should be Tailored to the individual needs of each resident. She further stated that it should specifically how to care for each resident, from ADL care to dietary, activities code status and plans for discharge. She stated that it should be updated as the needs of the resident change. A review of the care plan policy revealed the following excerpt: Policy: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing. On 6/7/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.5. The facility staff failed to review and revise Resident 50's care plan to include application of TED hose every day and to remove them nightly. Resident #50 was originally admitted to the facility 3/29/2024 after an acute care hospital stay and she had not been discharged from the facility. The resident's diagnoses included bilateral lower extremity edema The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/4/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. In section GG H. as dependent for putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. During the initial tour with Resident #50 on 6/4/24 at approximately 3:20 PM. The resident stated she experienced swelling in her feet and legs therefore she now required application of TED hose daily and to remove them prior to bed each night. The resident further stated because she can bath, dress and toilet herself she was having a difficult time getting staff to come in and apply the TED hose. The resident further stated she had tried but the TED hose were too tight for her to apply them unassisted. A review of Resident #50's orders revealed the following order dated 5/23/24 - TED HOSE - Please apply compression stockings every day for bilateral lower extremity edema. Take the TED HOSE off at night. The resident may help apply stockings to bilateral lower extremities. A review of the resident's care plan failed to identify the bilateral lower extremity edema problem and the intervention to apply the TED hose every day and remove them every night. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/7/24 11:40 AM. LPN #1 stated Resident #50 comes to the door and tells staff what her needs are and they follow through with her request for she does not require very much. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator, and two Corporate Nurse Consultants. They had no comments and voiced no concerns regarding the above information. Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise the care plan for 5 Residents (Residents #45, #359, #36, #161, and #50) in a survey sample of 62 Residents. The findings include: 1. For Resident #45, the facility staff failed to revise the care plan to include Eliquis anticoagulant therapy and assessment after a bilateral lung pulmonary embolus (blood clot) diagnosis in the hospital. Resident #45, was initially admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Atrial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. Resident #45 was also coded as requiring extensive dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders from the hospital were reviewed and revealed 2 orders for an anticoagulant. The orders were for the following; 1. 3-23-24 Apixaban (Eliquis) 5 mg (milligram) tablets take 2 tablets by mouth twice (20 mg per day) daily for 12 doses (6 days). Dispense 24 tablets. 2. 3-23-24 Apixaban (Eliquis) 5 mg tablets start 3-29-24 take 1 tablet by mouth twice (10 mg per day) daily for 90 days. Dispense 60 tablets with 2 refills. Guidance for the administration of anticoagulant medication is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Assess for signs of bleeding while taking this or any anticoagulant drug therapy. Resident #45's care plan was reviewed and revealed no care plan revision for anticoagulant drug use for pulmonary embolus, nor assessments for potential bleeding. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. Nursing staff agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks, and could cause bleeding. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that nursing care plans were not revised in March of 2024, however did state that interdisciplinary care plan meetings had not been done for a little over a month. The DON was a new staff member and had recently been hired in the last month. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to review and revise care plans. No further 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 ensure a complete list of orders were sent to the Home Health Agency upon resident's discharge for 1 of 62 residents (Resident #167), in the survey sample. The findings included: Resident #167 was originally admitted to the facility 10/02/21 and discharged on 10/22/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; End stage Renal Disease The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/08/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #167 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goal) the resident was coded as Independent with eating, Requires partial/moderate assistance with toileting hygiene and bathing/showering. The Care Plan dated 10/07/21 read that Resident #167 has infection of the (Osteomylitis left foot). The Goal for Resident #167 was the resident will be free from complications related to infection through the review date. The Interventions for Resident #167 was to administer meds/treatment as ordered. The October 2021 Physicians Order Summary (POS) Read: Zosyn Solution Reconstituted 2.25 (2-0.25) GM (Piperacillin Sod-Tazobactam So) Use 2.25 gram intravenously two times a day for UTI Verbal, Active 10/08/2021. The Medication Administration Record (MAR) for October 2021 read: Zosyn Solution Reconstituted 2.25 (2-0.25) GM (Piperacillin Sod-Tazobactam/Zosyn) Use 2.25 gram intravenously every 12 hours for antibiotic for 42 Days -Order Date-10/02/2021 2:56 PM., -D/C Date- 10/08/2021 6:30 PM. Zosyn Solution Reconstituted 2.25 (2-0.25) GM (Piperacillin Sod-Tazobactam So) Use 2.25 gram intravenously two times a day for UTI for 69 Administrations -Order Date-10/13/2021 2:00 PM., D/C Date- 10/22/2021 6:00 PM. The Ombudsman/Other Staff #17 alleged that the facility staff failed to arrange for continued IV therapy in home. Resident #167 was supposed to continue her therapy of IV Zosyn at home. Resident #167 was able to contact her infectious disease doctor to get orders to continue her IV therapy at home. However, the facility's failure delays her treatment for 6 days. The Ombudsman said that his review of the facility record revealed there were addendum notes dated 10-28-21 with instructions for IV therapy. A review of the Health Status Note on 10/21/21 at approximately 6:34 AM., revealed that Resident #167 was tolerating IV Zosyn for left foot infection with no adverse effects. A review of the discharged Instruction document dated 10/22/21 only shows the signature of Resident #167. The discharge Summary note dated 10/21/21 at approximately 1:00 PM revealed the following: patient received antibiotic (ABX) treatment via IV as scheduled. Patient states that she is doing well and overall looking forward to discharging home to continue with IV abx treatment. The discharge Medication list dated 10/21/21 included but not limited to Piperacillin Sod-Tazobactam So, Zosyn Solution Reconstituted 2.25 (2-0.25) GM, Use 2.25 gram intravenously two times a day for UTI. for 69 Administrations, 2.25 (2-0.25) GM, ACTIVE, 10/13/2021 to 11/17/2021. All written prescriptions to be given to patient upon discharge. Other instructions: Patient will need home health with Home Health Care with same instruction on how to administer IV ABX as it is BID dosing. The above instructions were written on 10/21/21 a day before the resident's discharge. A Discharge Summary Planning Progress Note dated 10/22/21 at approximately 4:30 PM., revealed that Resident #167 was discharged on Friday 10/22/21 around 5:00 PM., Transport home by family. Physician will write handwritten scripts. Home Health Care will provide skilled nursing care-wound care-PT/OT/HHA. Family Medical Supply will provide a wheelchair (w/c) that was delivered to the facility today,10/22/21. No other needs identified. According to the Discharge summary dated [DATE], the day of discharge does not indicate that Resident #167 received scripts for IV therapy. On 06/12/24 at approximately 1:06 PM., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 said that she does not remember the resident but normally we would print off all the scripts and give them to the Physician Assistant (PA) We would then go over the scripts with the resident. LPN #1 also mentioned that the PA will call in the scripts to a certain pharmacy. Several phone calls were made throughout the survey to contact the above resident and her emergency contact. No return calls were received. On 6/12/24 a phone call was made at approximately 12:14 PM., to the said Home Health Agency. An interview was conducted with the Director concerning Resident #167. The Director said that the agency only received a referral for rehab., and wound care but did not include IV therapy. We received the referral from the Nursing facility on 10/25/21 saying Wound Care only. The Director also said that on 10/26/21 the Infectious Disease doctor was contacted by the resident to initiate IV therapy. The agency Director also mentioned that the resident started receiving IV therapy services on 10/28/21 from their agency. On 6/12/24 at approximately 12:45 PM., documents were received from the Corporate Consultant Nurse (CCN) #1. The CCN had 2 copies of prescriptions dated 10/15/21: Hydromorphone-Acetaminophen Tablet 10-325 MG, give 1 tablet by mouth every 8 hours as needed. The other copy read the same as above but was dated on 10/06/21. The CCN said that was all she could fine on staff concerning the discharge scripts. Zosyn/Piperacillin/tazobactam Zosyn 2.25 Gram Intravenous Solution - Piperacillin/tazobactam is used to treat a wide variety of bacterial infections. Bacterial Infection- It is a penicillin antibiotic. It works by stopping the growth of bacteria. This medication is given by injection into a vein as directed by your doctor, usually every 6 hours. It should be injected slowly over at least 30 minutes. For the best effect, use this antibiotic at evenly spaced times. To help you remember, use this medication at the same time(s) every day. https://www.webmd.com/drugs/2/drug-16577/zosyn-intravenous/details. On 06/13/24 at approximately 2:00 p.m., 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #7 the facility staff failed to ensure a resident who was unable to carry out activities of daily living (ADL) receive the necessary services to include showers and washing her hair. Resident #7 was originally admitted to the facility 04/29/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Need for assistance with personal care and Low back pain unspecified. The Quarterly Revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/21/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #7 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as requires partial/moderate assistance with eating, oral hygiene, and personal hygiene. Resident is dependent with toileting hygiene and showers/bathes. The Care Plan dated 3/21/24 for read that resident #7 requires assistance with ADLS relate to CVA with weakness, inability to perform ADL. The Goal for Resident #7 would be to maintain her ADL functionality thru the review period. An intervention for Resident would be to provide a two person assist for bed mobility. The Physicians Order Summary (POS) Read: MUST WASH HAIR WITH NIZORALE SHAMPOO X2/WK. MONITOR FOR IMPROVEMENT OF DANDRUFF. DOCUMENT IN PCC THAT PT'S HAIR WAS WASHED WITH ABOVE SHAMPOO. SEE PCC FOR SPECIFIC ORDER FOR NIZORALE SHAMPOO, one time a day every Tue, Fri for Hair care; dandruff Prescriber Entered Active 04/15/2024. The Medication Administration Record (MAR) read: Nizoral External Shampoo 2 % (Ketoconazole (Topical)) Apply to To scalp topically one time a day every Mon, Thu for Cradle Cap / Dandruff for 8 Weeks until finished APPLY TO SCALP WHEN WASHING HAIR X2/WK -Order Date 06/07/2024. MUST WASH HAIR WITH NIZORALE SHAMPOO X2/WK. MONITOR FOR IMPROVEMENT OF DANDRUFF. DOCUEMENT IN PCC THAT PT'S HAIR WAS WASHED WITH ABOVE SHAMPOO. SEE PCC FOR SPECIFIC ORDER FOR NIZORALE SHAMPOO. one time a day every Tue, Fri for Hair care; dandruff -Order Date 04/15/2024 1533. A review of the shower schedule reveal that Resident #7 is scheduled for showers on Mondays and Thursdays. The 3P-11P shift. A review of the ADL sheet for June 2024 show that Resident #7 missed 1 shower on 6/06/24. A review of the ADL sheet for May 2024 show that Resident #7 missed 2 showers on 5/13/24 and 5/27/24. A review of the ADL sheet for June 2024 show that Resident #7 did not get her hair washed shower on 6/06/24. A review of the ADL sheet for May 2024 show that Resident #7 did not get her hair washed 5/13/24 and 5/27/24. A review of the most current order summary dated 6/04/24 at 3:36 PM., read: MUST WASH HAIR WITH NIZORALE SHAMPOO X2/WK. MONITOR FOR IMPROVEMENT OF DANDRUFF. DOCUMENT IN PCC THAT PT'S HAIR WAS WASHED WITH ABOVE SHAMPOO. SEE PCC FOR SPECIFIC ORDER FOR NIZORALE SHAMPOO, One time a day every Mon, Thu for Hair care; dandruff. During the initial on 06/04/24 at approximately 12:51 PM., Resident #7 was observed lying in her bed watching tv. The left side of resident's head/hair had thick, large, brownish/yellowish particles in her hair. The resident said that she would like to get her hair washed but doesn't. The resident also mentioned that she's only getting one shower a week but would like to get more. On 06/05/24 at approximately 11:23 AM., an interview was conducted with Resident #7. Resident #7 said that she gets a shower once a week on Thursday but would like more. Resident #7 also said I don't remember the last time I got my hair washed. Shortly after LPN #1 entered the room said that Resident #7 was refusing her special shampoo. LPN #1 was asked to present any refusal documentations concerning ADL care. On 6/06/24 at approximately 11:36 AM., Resident #7 was observed lying in bed. Hair observed to have thick, brownish/yellowish flakes on the right side of her head. Resident #7 said that she had a bed bath but didn't get her hair washed. On 6/12/24 at approximately 10:40 AM., an interview was conducted with Certified Nursing Assistant (CNA) #6 concerning ADL care. CNA #6 said that asked if a resident refuses showers, baths, ADL care, the nurse should be informed. On 6/12/24 at approximately 11:00 AM., an interview was conducted with CNA #6. CNA #6 said that residents are supposed to get two showers a week and get their hair wash during their showers. CNA #2 also said that if a resident refuses a shower, they will get a bed bath and if a bed bath is refused, they will inform the resident's nurse. On 06/12/24 at approximately 1:06 PM., an interview was conducted with Licensed Practical Nurse (LPN) #1 concerning Resident #7. LPN #7 said that the resident's daughter spoke to her on yesterday to ensure she gets a shower and her hair washed on the 3-11 shift. LPN#1 also stated that Resident #7's shower days are on Monday and Thursdays on the 3-11 shift. She also said that the resident got her hair washed on yesterday and there are no flakes showing in her hair afterwards. LPN #7 also mentioned that the resident ran out of special shampoo, but the Physician Assistant (PA) was recently made aware. On 06/13/24 at approximately 2:00 p.m., 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 observation, interview, clinical record review and facility documentation, the facility staff failed to provide ADL (Activities of Daily Living) care 7 Residents (#'s 13, 161, 258, 7, 171, 5 and 165 ) in a survey sample of 62 Residents. The findings included: 1. For Resident #13 the facility staff failed to provide incontinence care in a timely manner leaving Resident #13 in brief that was visibly soiled. 6/4/24 at 11:30 AM, Resident #13 was laying in soiled brief notable urine and feces odor in room. Sheets soiled with brownish yellow stain on left side of the bed. Resident #13 asked if the staff have been in to provide incontinence care and she stated that they had not been in since they collected the breakfast trays and had not provided incontinence care since before breakfast. 6/4/24 at 12:00 AM , Resident feces odor remained in room has still not been changed. On 6/4/24 at 1:00 PM, Corporate Employee #1 stated that the facility does not have a policy on ADL Care, she stated they use Mosby's Professional Nursing standards. On 6/4/24 at 2:00 PM, Resident #13 still had not been attended to for incontinence care. Regional nurse consultant came with surveyors to the room and observed the odor in the room and the stains on the sheets. She stated that it was obvious that incontinence care had not been provided timely. When asked the importance of timely incontinence care for dependent Residents she stated that it prevents skin irritation and breakdown and also for the comfort of the Resident. On 6/4/24 during the end of day meeting the Administrator was made aware of the concerns and stated that there was a mix up in the scheduling and the assigned CNA was unaware that Resident #13's room was assigned to them. No further information was provided. 2. For Resident #161 the facility staff failed to ensure adequate bathing and hygiene. On 6/5/24 a review of the clinical record revealed that Resident #161 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, malnutrition, respiratory failure, and history of fall with injury. A review of the closed clinical record revealed that during the time of the admission Resident #161, did not receive scheduled showers on 2/19, 2/27, 3/1, 3/12, 3/16, 3/19, and 3/22. These were not coded nor documented as refusal by the Resident. On 6/6/24 an interview was conducted with CNA #5 who was asked how often Residents receive showers, CNA #5 responded that all Residents were scheduled for 2 showers a week. When asked what is documented if a Resident refuses, CNA #5 stated if a Resident refuses a shower, We notify the nurse and document in our POC (Point of Care) notes that the Resident refused, and we try to find out if they want to do it another time or if they just don't want shower at all. We also are supposed to try again later and offer a bed bath instead. CNA #5 was asked about documenting Codes in POC. When asked what the codes 1/8/8 meant, CNA #5 stated that the first number is for if the shower was given, # 1 is No the Resident did not get a shower. CNA #5 stated the second number is 8 meaning the activity did not occur and the third number is how much help they required which was also 8 activity did not occur. When asked if the Residents prefer bed baths how often should that occur, CNA #5 stated that if the resident does not like to shower then daily bed baths should be given. A review of the clinical record for the duration of the admission revealed that Resident #161 did not receive daily bed baths. On 6/6/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 3. For Resident #258 the facility staff failed to provide adequate showers and nail care. Resident #258 was admitted to the facility on [DATE] with diagnoses that included but were not limited to malnutrition, dementia, weakness, abnormality of gait, and history of falls, his most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/31/24 coded him as having a BIMS (Brief Interview of Mental Status) score was 7/15, indicating severe cognitive impairment. On 6/4/24 at approximately 11:20 PM, Resident #258 was observed in bed wearing a hospital gown and no socks, sheets pulled over legs feet exposed. Resident #258 appeared disheveled and had long nails. Resident #258 was asked about getting out of bed and he stated that he gets out of bed when his son comes to visit. When asked if he gets up more often than that he stated that he only gets out of bed when family visits. At that time, it was noted that Resident #258's nails were approximately 1/4 -1/2 an inch over the tips of his fingers, they appeared to have dark debris under the nails. When asked about cutting nails Resident #258 stated, Yes I would like my nails cut. On 6/4/24 a review of the clinical record revealed that Resident #258 had been admitted to the facility on [DATE] and since then has only had 1 of the 4 scheduled showers. On 6/5/24 at approximately 12:30 PM Resident #258 was again observed in his bed appearing disheveled and nails continued to be long with debris under the nail. Family member was at the bedside and when asked about Resident #258's care the family member stated that Resident #258 did need his nails cut but was not sure if the facility would do it or if the family was expected to do this. On 6/5/24 at approximately 2:00 PM an interview was conducted with the DON who was asked the expectation of CNA's (Certified Nursing Assistant's) with regard to nail care. The DON stated that routine nail care should be provided on shower days by the CNA unless the Resident has diabetes or PVD (Peripheral Vascular Disease) or some other condition that would make it unsafe for a non-licensed person to do it. On 6/5/24 an interview was conducted with Corporate Employee #1 who stated they do not have a policy on ADL Care. On 6/6/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 6. For Resident # 5, the facility staff did not provide timely incontinence care. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. During an interview on 6/4/2024 at 11:45 a.m., Resident # 4 stated the staff often did not provide incontinence care and she was left soiled for extended periods of time. The room had a pungent odor of urine and feces. Dark brownish colored liquid substance was observed on the bottom sheet with the line of demarcation reaching to level of Resident # 5's hips. The dark substance was noted on the bedspread and top sheet as well. The room was very foul smelling. On 6/4/2024 at 12:10 p.m., Licensed Practical Nurse-1 entered Resident # 5's room and obtained a finger stick blood sugar. LPN-1 was accompanied by a student nurse who stated she was in orientation. LPN-1 and the student nurse did not comment about the pungent odor in the room nor about the brown liquid substance that was evident on the bed sheets and linen. The nurse removed the lid on the lunch tray, Resident # 5 looked at the food and stated she did not want to eat the food. She said it did not smell good and she did not want an alternate meal. LPN-1 stated that Resident # 5 often ordered food from outside restaurants. Resident # 5 stated she did not want any restaurant food either. On 6/4/2024 at 1:15 p.m., Resident # 5 was observed still lying in bed. The room still had the pungent odor of urine and feces. The line of demarcation of the brownish colored liquid was creeping higher up the sheets to approximately the waist level. On 6/4/2024 at 1:45 p.m. and 2:15 p.m , there were observations of Resident # 5 still lying in bed with dark brown liquid stains on the sheets which had increased in size to reach to the middle of Resident # 5's back. There was a pungent odor of urine and feces in the room. During an interview on 6/4/2024 at 2:15 p.m., Resident # 5 stated they haven't changed me yet. They haven't done it since early this morning. Resident # 5 stated she needed to be changed. There were no nursing staff observed in the hallway. On 6/4/2024 at 2:19 p.m., the Corporate Nurse Consultant was asked to come to Resident # 5's room. The Corporate Nurse Consultant came to the room and immediately stated it was evident that Resident # 5 had not had incontinence care for an extended period of time. The room reeked of urine and feces. There were lines of demarcation indicating the urine and feces had crept up higher at different times. The Corporate Nurse Consultant stated she would get someone to provide are immediately. On 6/4/2024 at 2:30 p.m., Resident # 5's door was closed. One Certified Nursing Assistant was observed coming out of Resident # 5's room carrying two clear bags of soiled linen. Feces and urine stains could be visualized on the linens. The Certified Nursing Assistant was asked what she was doing. She stated she had just helped the other CNAs provide incontinence care to Resident # 5. She stated the resident had been incontinent of both urine and feces and all of the linens were soiled. The odor was pungent. She stated incontinence care should be provided every two hours and as needed. She stated she did not know why incontinence care had not been provided earlier. Review of Resident #5's physician orders, Medication and treatment administration records (MAR's/TAR's), Care plan, and progress notes indicated that the Resident suffered from moisture associated dermatitis (MASD) and had a history of a pressure ulcer on the sacrum. The Resident was ordered to have moisture barrier cream applied to the sacrum, and the Resident wore incontinence products/briefs. On 6/4/2024, the Director of Nursing (DON), and Administrator were interviewed and asked what their expectation for toileting and incontinence care timing was for this resident. They stated every 2 hours, and as needed, and that the care must be documented after provision of care to the resident. Certified Nursing Assistants (CNA's) were interviewed on all three units during survey, and indicated they documented all care in the Point of Care computerized system for each of their residents at the end of every shift. On 6/5/2024 at 9:20 a.m., an interview was conducted with Certified Nursing Assistant-3 who stated they turn and reposition residents every 2 hours but sometimes every hour depending on the needs of the resident. CNA-3 stated incontinence care should be given every hour or even 30 minutes if needed. She also stated showers should be given at least twice a week and more often if needed or if the resident requests one. Resident # 5's point of care documentation by primary care staff to indicate care that was given every day was reviewed. The facility instituted 8 hour working shifts for staff, and those 3 shifts were 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. The records indicated that for the months of April 2024, May 2024 and June 2024, Resident # 5 was totally dependent on staff for toileting and incontinence care. The record further documented the following but not limited to: In May 2024, Resident #5 did not receive toileting and incontinence care every 8 hour shift. There were 25 of 90 shifts with missing documentation during May 2024. In June 2024, there were 5 of 15 shifts with missing documentation. The Corporate Nurse Consultant stated the facility did not have a policy on ADL (Activities of Daily Living) care. She stated the expectation was that care would be provided approximately every 2 hours every shift and PRN (as needed), which included removal of wet incontinent briefs, and cleansing. Interviews were conducted with staff members by the survey team. Staff members stated that the expectation was to give incontinence care immediately after every incontinent episode. Resident # 5 was not afforded timely incontinence care. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debrief on 6/5/2024. No further information was provided. 5. The facility staff failed to carry out activities of daily living necessary to maintain good grooming and personal hygiene for a dependent resident, Resident #171. Resident #171 was originally admitted to the facility 6/3/24 after an acute care hospital stay. The current diagnoses included metastatic cancer involving the liver, lungs, chest wall and the brain. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 6/3/24. The tool revealed at number 1. Cognitive state, that the resident was oriented to person, place, and time, at number 8. Gastrointestinal, the resident was incontinent of bowels, at number 9. Genitourinary, the resident was incontinent of bladder, at number 12.GG that the resident required Partial/moderate assistance with eating and oral care, was dependent with toileting hygiene, and the resident was not assessed to move from sitting on side of bed to lying flat on the bed, to come to a standing position from sitting in a chair, and with transfers. On 6/4/24 at approximately 10:05 A.M., Resident #171 was observed in bed observed in bed unshaven, with dry lips and disheveled. On 6/5/24 at approximately 10:47 A.M., Resident #171 was again observed in bed with a urine saturated drawsheet with multiple brown rings on it. The gown was also noticeable wet through the wet sheet, the resident was unshaven and did not smell clean. He was also in the same position as he was observed in on 6/4/24, facing the door. The information was reported to Corporate Nurse Consultant #1. Corporate Nurse Consultant #1 and Corporate Nurse Consultant #2 stated they would ensure the resident received the necessary activities of daily services to promote comfort. The Corporate nurses were observed providing the resident's hygienic care. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator, and two Corporate Nurse Consultants. The above findings were shared with them. An opportunity was offered to the facility's staff to comment but they offered voiced no concerns regarding the conveyed information. 7. For Resident #165, the facility staff failed to provide timely ADL care to a dependant Resident. Resident #165 was admitted to the facility on [DATE], and discharged on 4-20-21 (29 days later) with diagnoses including; Diabetes type 2, acute hip fracture with surgical repair, Foley urinary catheter placement after hip fracture, and congestive obstructive pulmonary disorder (COPD). Resident #165's most recent MDS (Minimum Data Set Assessment) was an admission assessment. The MDS coded Resident #165 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as alert and able to make needs known, with some confusion at times. The Resident was coded as frequently incontinent of bowel and a Foley catheter for bladder. The Resident was no longer in the facility and a closed record review was conducted. The Resident had no pressure wounds upon admission. Physician orders were reviewed and revealed that on 3-23-21 after admission the Resident was receiving an Allevyn cushion dressing to the sacrum from the hospital every day for protection, and skin prep wipes to heels every shift for protection prior to the development of the pressure sores. This indicated that the facility staff were aware of the risk potential for skin breakdown for Resident #165. No other preventive measures were put in place for the immobile Resident with a surgical repair for her fractured hip which increased the likelihood of skin impairment. Resident #165's Activity of daily living sheets documented the incontinence/hygiene, and bathing care provided for the Resident. Review of those documents revealed that during the month of April 2021 personal hygiene was not given for the following dates and shifts; On 4-9-21, and 4-14-21, (7am to 3pm) day shift staff documented extensive assistance from 1 staff member required by the Resident for personal hygiene care. No other day shifts were documented as hygiene care having been given on this 8 hour shift during the 20 day period (18 days missed) from 4-1-21 through discharge on [DATE]. On 4-1-21, 4-2-21, 4-4-21, 4-5-21, 4-13-21, 4-14-21, 4-16-21, and 4-19-21, (3pm to 11pm) evening shift staff documented total dependence from 1 staff member required by the Resident for personal hygiene care. No other evening shifts were documented as hygiene care having been given on this 8 hour shift during the 20 day period (12 evenings missed) from 4-1-21 through discharge on [DATE]. Bathing care was documented as being planned for Monday, Wednesday, Friday 7am to 3pm shift (day shift). Those baths did not occur on 4-2-21, 4-5-21, 4-12-21, and 4-19-21, and the Resident was documented as completely dependant on one staff member for bathing. Eight (8) opportunities for baths were planned from 4-1-21 through 4-20-21, and only 4 were given. The Director of Nursing (DON) was asked what her expectation was for incontinence rounds and skin breakdown assessment. Her reply was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNA's (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. The nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent worsening. Resident #165 was not afforded timely bathing, nor hygiene/incontinence care. During the course of the survey multiple Residents in the survey sample, and still residing in the facility were found to have not been afforded timely hygiene/incontinence care and bathing. On 6-7-24 during the end of day meeting the Administrator and Regional Nurse Consultant were made aware of the above findings. The Administrator stated that this happened before her tenure, and with a different owner. She stated she had no additional information to provide to the survey team.

**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 staff failed to perform physician ordered pain assessments, topical and oral medications for 1 of 62 residents (Resident 166), in the survey sample. The findings included: Resident #166 was admitted to the facility with diagnoses that included but were not limited to Fracture of scapula, right shoulder, Osteoporosis, aortic valve disorder, history of falls, malignant neoplasm of upper lobe right bronchus, hypertension, bilateral osteoarthritis of knees, history of venous thrombosis, dementia without dementia without behaviors, and abnormality of gait. Resident #166 admitting orders included the following: Pain Assessment using 0-10 scale or non-verbal scoring tool every shift for Monitor -Order Date- 01/04/2024 - D/C (Discontinued) Date-02/20/2024. Acetaminophen Oral Tablet 500 MG Give 2 tablet by mouth three times a day for Pain -Order Date- 01/04/2024 -D/C Date-01/29/2024. Lidocaine Pain Relief External Patch 4 % Apply to Bilateral Knees topically every 12 hours for Pain -Order Date-01/04/2024 -D/C Date- 01/29/2024 A review of Resident #166's care plan read: FOCUS: The resident has a risk for pain related to gout, arthritis, osteoarthritis, fracture right scapula. Created on: 01/06/2024. GOAL: The residents pain will be resolve thru review period Created on: 01/06/2024 INTERVENTION: Administer medications as ordered Date Initiated: 01/06/2024 Notify MD as indicated Date Initiated: 01/06/2024. Observe for physical indicators of pain Date Initiated: 01/06/2024. A review of the MAR (Medication Administration Record) revealed the following dates and times of missed doses of pain medications and treatments as well as missing pain assessments. Pain Assessment - From admission on [DATE] until the discharge on [DATE] the following pain assessments were not documented: Day Shift - 1/29, 2/5 Evening Shift - 1/20, 1/25, 1/29, 2/7 Night Shift - 1/22, 1/26, 2/8, 2/9 Acetaminophen - From admission on [DATE] until the order was changed on 1/29/24 the following doses were not documented as given: 6:00 AM - 1/23, 1/27 2:00 PM - 1/28, 1/29 9:00 PM - 1/16, 1/20, 1/22, 1/25 Lidocaine Patches - From admission on [DATE] until the order was changed on 1/29/24 the following doses were not documented as given: 9:00 AM - 1/4, 1/23 9:00 PM - 1/16, 1/20, 1/22, 1/24, 1/25 On 6/11/24 an interview was conducted with the DON who was asked what the expectation was if a medication is ordered, she stated, It is expected that the Resident will receive all medications as ordered by the physician. When asked what the nurses responsibility was if a medication dose is missed or not given for any reason, the DON stated, If any medications are not administered for any reason the nurse should notify the physician and the Resident or the RP (Responsible Party). When asked what the importance of notifying the physician would be she stated, In case the physician wants to give a onetime order for another med or to give a one-time order to 'give now' if it is outside of the time frames for administration. On 6/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided prior to the survey's exit.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure residents who use psychotropics receive gradual dose reduction and are free from unnecessary psychotropic medications for one (1) resident (Resident #13) in a survey sample of 62 Residents. The findings include: The resident was admitted with diagnoses that included muscle weakness, scoliosis, hypotension, history of falls, anxiety disorder unspecified, insomnia, osteoporosis, atrial fibrillation, major depressive disorder, hypertension, psychophysiological insomnia, hx of transient ischemic attack, and protein calorie malnutrition. On the morning of 6/10/24 a review of the clinical record revealed the following orders for psychotropic medications for Resident #13: Duloxetine HCL (trade name Cymbalta, an anti-depressant) oral cap. Delayed release, 60 mg Give 1 cap by mouth one time a day order date 9/16/23. Zolpidem Tartrate (trade name Ambien, a hypnotic) tab. 5 mg. Give 1 tablet by mouth at bedtime for insomnia. Take 5mg (1 tab) at bedtime nightly. 2/27/24 Buspirone HCL (trade name, Buspar an anti-anxiety) oral tab 5 mg. Give 1 tablet by mouth three (3) times a day for anxiety order date 4/29/24. Trazodone HCL (trade name Dyserel, an anti-depressant) oral tab 50 mg. Give .5 tablet by mouth at bedtime for insomnia order date 5/16/24. On 6/10/24 at approximately 4:00 PM an interview was conducted with the DON who was asked about GDR (Gradual Dose Reduction) for Resident #13, she stated that should be in the MDS (Minimum Data Set). When shown the MDS section N for GDR and asked what the symbol ^ meant in the column for GDR she stated it meant it was not done. A review of the MDS for 2/8/24 Quarterly and 5/10/24 Quarterly show no GDR attempts. On 6/10/24 after the discussion with the Regional Nurse Consultant and DON the order was changed to read Trazadone HCL oral tablet 50 mg Give 0.5 tab by mouth at bedtime for depression / anxiety with restless sleep pattern (insomnia) 6/10/24. A review of the clinical record was conducted, and no documentation was found to state that a GDR was contraindicated in Resident #13. On 6/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #358 was admitted to the facility on [DATE], status post left knee revision from an acute care hospital. Diagnoses for Resident #358 included but were not limited to hypertension, hypercholesterolemia, left knee revision, and left knee infection. Resident #358 order summary dated 5/22/24 has intravenous (IV) Vancocin (vancomycin) ordered daily until 6/29/24 for a left knee infection. A review of Resident #358 clinical records indicated that due to lack of access or not having vancomycin available, the resident missed doses on June 1,2,6, of 2024. Review of the facility policy, General guidelines for medication administration by Pharmascript effective 9/2018 and revised 8/2020 .Medications are administered in accordance with written orders of the prescriber . The above findings were shared with the Administrator, Corporate Nurse #1, and Corporate Nurse #2 on 6/13/2024 at approximately 11:45 AM. No further information was provided prior to the conclusion of the survey. 3. For Resident # 23 the facility staff held medications without a physician order and or notification to the physician. Resident #23 was readmitted to the facility on [DATE] with diagnoses that include but are not limited to hypertension, Paroxysmal Atrial Fibrillation, adult failure to thrive, history of Malignant Neoplasm of Prostate Protein -Calorie malnutrition, chronic respiratory failure with hypoxia, dependence on enabling machines or devices and dysphagia. On 6/10/24 a review of the clinical record revealed that Resident #23 had the following orders for blood pressure medications. Atenolol Oral Tablet 50 MG (Atenolol) Give 1 tablet by mouth one time a day for htn -Order Date- 05/07/2024. Diltiazem HCl Oral Tablet 60 MG Give 1 tablet by mouth three times a day for htn -Order Date- 05/07/2024. The medications were being coded as #4 Outside parameters or #9 see progress notes. A review of the progress notes revealed that the Nurses were entering a note that states the medication was held due to low bp, however no documentation was found to support holding the blood pressure medication as the order does not specify parameters. On 6/11/24 at approximately 4 PM an interview was conducted with the NP who stated that she 6/8/24 not given coded as #4 - Outside of parameters. Diltiazem was coded as not given on 5/8, 5/12, 5/21, 6/3 and 6/10/24 at 6 AM and on 5/12/24 at 2 PM and on 5/22, 5/28, 5/30, at 10 PM. On the morning of 6/11/24 an interview was conducted with the DON who stated that nurses can hold medications for Nursing Judgement if a blood pressure reading is too low, however, they should be making the physician aware the Resident or Resident Family, and documenting in the nursing notes everything that was done and what the physician response was. On the afternoon of 6/11/24 an interview was conducted with the NP (Nurse Practitioner) who was asked if she was aware of Resident #23's blood pressure medications being held per Nursing Judgement for low blood pressure, the NP stated, I understand they can hold it for nursing judgement but then someone should have notified me so that I can put parameters in place so they know when I consider it too low to give. On 6/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 4. For Resident # 166 the facility staff failed to administer anti-coagulant, and anti-hypertensive medications as ordered by physician. Resident #166 was admitted to the facility with diagnoses that included but were not limited to Fracture of scapula, right shoulder, Osteoporosis, aortic valve disorder, history of falls, malignant neoplasm of upper lobe right bronchus, hypertension, bilateral osteoarthritis of knees, history of venous thrombosis, dementia without dementia without behaviors, and abnormality of gait. On 6/6/24 a review of the clinical record revealed that Resident #166 had orders that included: Cozaar Oral Tablet 50 MG Give 50 mg by mouth one time a day for Hypertension. This medication was not given on 1/5/24. Eliquis Oral Tablet 2.5 MG Give 2.5 mg by mouth two times a day for History of DVT [Deep Vein Thrombosis]. This medication was not administered on 1/16/24, 1/20/24, 1/22/24, or 1/25/25 at 9 pm. On 6/11/24 an interview was conducted with the DON who was asked what the expectation is if a medication is ordered, she stated it is expected that the Resident will receive all medications as ordered by the physician. When asked what the nurses responsibility is if a medication dose is missed or not given for any reason, the DON stated that if any medications are not administered for any reason the nurse should notify the physician and the Resident or the RP (Responsible Party). When asked what the importance of notifying the physician would be she stated, In case the physician wants to give a onetime order for another med or to give a one-time order to 'give now' if it is outside of the time frames for administration. A review of the clinical record revealed no adverse outcomes as a result of the missing medications; however, the physician and RP were not documented as being notified. On 6/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to prevent significant medication errors for five (5) Residents (Residents #45, #49, #23, #166 and #358) in a survey sample of 62 residents. The findings included: 1. For Resident #45, the facility staff failed to administer Eliquis anticoagulant medication after a bilateral lung pulmonary embolus (blood clot) diagnosis in the hospital with a specialist doctor's ordered dose Resident #45, was initially admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. Resident #45 was also coded as requiring extensive dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders from the hospital were reviewed and revealed 2 orders for an anticoagulant. The orders were for the following; 1. 3-23-24 Apixaban (Eliquis) 5 mg (milligram) tablets take 2 tablets by mouth twice (20 mg per day) daily for 12 doses (6 days). Dispense 24 tablets. The original 10 mg dose ordered twice daily for 12 doses (6 days) was only given for 3 days on 3-25-24, 3-26-24, and 3-27-24. The Resident only received once daily 10 mg evening doses on 3-24-24, 3-28-24, and 3-29-24, for a half dose each day. The other 10 mg evening doses were omitted. 2. 3-23-24 Apixaban (Eliquis) 5 mg tablets start 3-29-24 take 1 tablet by mouth twice (10 mg per day) daily for 90 days. Dispense 60 tablets with 2 refills. The Medication and Treatment Administration Records (MAR/TAR) was reviewed for March, April, may, and June 2024, and revealed the absence of nursing signatures on multiple occasions. Those follow; 9:00 am dose - 4-14-24, 4-21-24, 4-25-24. 6:00 pm dose - 3-23-24, 3-24-24, 3-28-24, 3-29-24, 4-7-24, 4-17-24, 6-1-24, and 6-3-24. Nursing medication administration notes do not indicate why the medications were not administered as ordered, and why they were omitted. Guidance for the administration of anticoagulant medication is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Anticoagulant medication must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Resident #45's care plan was reviewed and revealed no care plan revision for anticoagulant drug use for pulmonary embolus, nor assessments for potential bleeding. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 or a 5 on the medication administration record (MAR), that the medication was not administered. Nursing staff further agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, and that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to prevent significant medication errors in omitted medications as ordered. No further information was provided. 2. For Resident # 49, Facility staff failed to Administer Lovenox (anticoagulant) and Keflex (antibiotic) medication. Resident #49, was admitted to the facility on [DATE], and discharged to the emergency room with an infected wound on 4-19-24. The Resident returned on 4-24-24. Diagnoses included; After care following hip fracture, alzheimers disease, stage 4 sacral pressure sore, hypertension, hypothyroid, stroke, malnutrition, aphasia, dysphagia, and aspiration pneumonia. Resident #49 was a bed bound patient with severe cognitive impairment. Resident #49 was documented as being totally dependant on staff for all activities of daily living such as hygiene, transferring, and bed mobility. The Resident was incontinent of bowel and bladder. The Resident's physician orders were reviewed and revealed orders for anticoagulants and antibiotics. The orders were for the following; 1. Ordered 4-24-24 at 2:59 pm, Lovenox inject 0.4 milliliters subcutaneously one time per day for 20 days. 2. Ordered 5-13-24 at 9:43 am, Cephalexin/Keflex 500 milligrams tablet every 12 hours at 9:00 am, and 9:00 pm, for urinary tract infection for 8 administrations. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April and May of 2024 2024, and revealed the absence of nursing signatures on some occasions, and a signature with the number 5 added to it indicating the medications were not administered. Those follow; Lovenox not administered; 4-25-24, 4-26-24, 5-13-24, 5-14-24, 5-15-24, at which time it was discontinued with only 17 doses given omitting 3 doses. Keflex not administered: 5-15-24 at 9:00 am, and it was discontinued on 9-17-24 after the 9:00 am dose having administered 7 of 8 doses. Nursing medication administration notes do not indicate why the Lovenox and Keflex were not administered as ordered, and why they were omitted. Guidance for the administration of Antibiotics and Anticoagulants is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Antibiotics must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Antibiotics increases the likelihood of MDRO's (multi drug resistant organisms) such as Methycillin Resistant Staphyloccocus Aureus (MRSA), and can result in rebound infections which can be life threatening. National Institutes of Health & Medline.gov; Anticoagulant medication must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Resident #49's care plan was reviewed and revealed a care plan for Anticoagulant medications, however, it was not revised to include a care plan for urinary tract infections and antibiotic use. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 or a 5 on the medication administration record (MAR), that the medication was not administered. Nursing staff further agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks, and withholding antibiotics could cause a rebound infection. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, and that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to ensure medication administration per physician's orders. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident # 5, the facility staff failed to store eye drops in the medication cart. The resident was allowed to keep them at the bedside. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. On 6/5/2024 at 9:30 a.m., a plastic prescription bag with an affixed label Bremonidine 0.2 % eye gtts (drops) was noted on Resident # 5's overbed table. Resident # 5 stated she kept the eye drops at her bedside because the staff members kept losing her eye drops. Resident # 5 stated that she was diagnosed with glaucoma and she was very concerned about not getting the eye drops on time. Resident # 5 stated she would give the eye drops to the nurses when it was time to administer them. On 6/5/2024 at 10:05 a.m., the bag with the eye drops was still on the overbed table. On 6/5/2024 at 10:20 a.m., the eye drops were still on the overbed table. On 6/5/2024 at 10:30 a.m., an interview was conducted in the conference room with the Director of Nursing and Corporate Nurse Consultant. Both stated that medications should not be kept at the bedside without the resident being assessed for self administration of medications. Both stated that medications should be kept on the medication cart until time for administration. Review of the clinical record revealed an order for Bremonidine 0.2 % eye gtts instill one drop in both eyes Brimonidine Tartrate Solution 0.2 %- Instill 1 drop in both eyes two times a day for glaucoma -Order Date 07/29/2022 1253 There was no documentation of eye drops being administered on 4/21/2024 at 9 a.m. and 4/30/2024 at 5 p.m. Review of the physicians orders revealed no orders for the medication to be left at the bedside. During the end of day debriefing, the Administrator and Corporate Nurse Consultant were informed of the findings. They were asked to provide any information about eye drops not being administered by nurses due to the medication not being available. No further information was provided. Based on observations, resident interview, staff interview and clinical record review, the facility staff failed to ensure medications were stored properly in the refrigerator and on the medication carts. The findings included: 1. On 6/10/24 at approximately 12:40 PM the medication storage task was completed with Licensed Practical Nurse (LPN) #2. In the refrigerator in the medication room along with medication to be administered was an opened vial of purified protein derivative (PPD), which was absent of the date it was opened. There were also four single dose COVID-19 vaccines with expiration dates of April 2024. 2. Also on 6/10/24 at approximately 1:07 PM the medication cart that serviced Hall #3 was inspected with LPN #6. In the medication cart were three opened bottles of Latanoprost ophthalmic drops for Resident #50. The oldest bottle was dated 4/23/24, another 5/11/24 and 5/24/24. LPN #6 left the cart and Registered Nurse (RN) #2 completed the inspection. RN #2 stated that Latanoprost ophthalmic drops could be used for six weeks after they were opened and after six weeks it is recommended to discard the drops, even if there were some still left inside the bottle. That meant that the 4/23/24 bottle of Latanoprost ophthalmic drops should have been discarded on 6/4/24 if they were opened on 4/23/24. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator, and two Corporate Nurse Consultants regarding the above findings. They voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one Resident (Resident # 5) received routine and emergency dental care. The Findings included: For Resident # 5, the facility staff failed to schedule routine and emergency dental care appointments. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. On initial tour, Resident # 5 was observed sitting up in bed. The lower bottom teeth were in obvious need of repair as evidenced by noticeable dental caries. Resident # 5 stated her teeth hurt. Review of the clinical record was conducted 6/4/2024-6/7/2024. Review of the Progress Notes revealed that Resident # 5 complained of tooth pain several times. Review of the April 2024, May 2024 and June 2024 Medication Administration Records revealed documentation of an order written on 4/25/2024 which stated: DENTIST APT (appointment) - Pt (patient) requesting Dentist apt (appointment), 'teeth are hurting' Please schedule apt. Pt thinks that she goes to Dr. __________(name redacted) office. every shift for Teeth are hurting -Order Date- 04/25/2024 1655 There were initials on most shifts on the MARs indicating that the task was completed. Review of the Progress Notes revealed no documentation of an appointment with a dentist since the order was written on 4/25/2024. There was documentation on 6/2/2024 on 11-7 shift where a nurse wrote : 06/02/2024 00:58 Type: Orders - Administration Note Note Text : Can not make dental appointment 11-7 on a weekend. On 6/6/2024 at 2:10 p.m., the Administrator and Corporate Nurse Consultant were informed of Resident # 5 complaining of tooth pain and no apparent follow up was noted in the clinical record. Review of the care plan revealed documentation of a problem of oral/dental health problems on admission There were 2 interventions to address the problem and goals: Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. · Provide mouth care as per ADL(Activities of daily living) personal hygiene. There was no mention of referring the resident to the Dentist. There were no noted scheduled dental appointments according to the clinical record. Resident # 5 stated she needed to see the dentist. During the end of day debriefing on 6/6/2024, the facility Administrator and Corporate Nurse Consultant were informed of the findings that Resident # 5 had not received Dental services. On 6/7/2024 at 3:10 p.m., a telephone interview was conducted with the Administrator who stated she did not have any information about any dental visits for Resident # 5. The Administrator stated she would immediately send a copy of the facility's policy on Dental care. The policy was submitted to the surveyor. Review of the policy revealed the following documentation: POLICY In the event a patient is in need of routine or emergency dental services, a licensed nurse will initiate and coordinate the necessary care. Under PROCEDURE was written the following: 1. Nursing will notify the provider and obtain a consult recommendation. 2. Nursing will collaborate with the Social Services Department to identify and secure designated and/or centered contracted community available resources for dental services. 3. Nursing will, if necessary or if requested, assist the patient in making appointments and/or arranging transportation to and from the dental services location. Also. 5. The Social Services Department will coordinate with the business office to assist the patient for dental service associated payments. Patients who are eligible and wish to participate may apply for reimbursement of dental services under the Medicaid Plan. Further review of the clinical record revealed no documentation that an appointment was made for Resident # 5. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, facility document review, clinical record review, staff interview, and Resident interview the facility staff failed to follow the menu and preferences of one (1) Resident (Resident #45) in the survey sample of 62 residents. For Resident #45 the tray ticket, and menu, were not followed for the breakfast and lunch meals on 6-4-24, 6-5-24, and 6-6-24. The findings included; Resident #45, was admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. The Resident was also coded as requiring extensive dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. On 6-4-24 at 12:00 noon, Resident #45 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that I didn't get lunch or breakfast today, but someone is getting me some soup now. At that time the dining services director entered the room with a tray which contained 1/2 cup scoop of canned tuna unaltered, 1 cup of clear broth, 2 packages of saltine crackers with 2 crackers in each package, 1 cup of grapes, and a clear plastic water glass with 120 milliliters of iced tea. The dining services director stated I don't know how her meal ticket didn't get printed today, but this will help, she loves tuna. The Resident agreed that she did love tuna. On 6-4-24 At 12:15 pm the surveyor followed the Dining Services Director (DSD) back to the kitchen and received the meal tray tickets for that day. The tickets listed for breakfast that morning she should have received oatmeal, and for lunch spaghetti and meat balls. The (DSD) was asked why the Resident would receive oatmeal, crackers, and pasta for all 3 meals that day when she was gluten intolerant. The DSD stated someone made a mistake. On 6-5-24, at lunchtime the Resident was noted to have fried rice for lunch with soy sauce, and stewed tomatoes with bread in them. She stated she got oatmeal again this morning, all of which contained gluten. The meal tickets were again requested and the items were plainly printed on the tray ticket as observed during meals. On 6-6-24 at lunch the Resident was again visited and her meal ticket obtained from the tray itself. The ticket read Ground baked ham, orange twist, collard greens, roasted red potatoes, whole milk, hot coffee or tea. The ground baked ham and collards were the only thing on the tray included on the menu. Instead the Resident had mashed potatoes, peach cobbler, and iced tea 120 milliliters. The cobbler contained gluten. The meals which were served to the Resident was not what the menu planned, nor what the Resident preferred, and there was only one 4 ounce drink on each tray observed. All meal tickets documented Allergies: Gluten. On 6-6-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. the Administrator stated there should be at least 2 drinks on every tray, and the menu should be followed. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, facility document review, clinical record review, staff interview, and Resident interview, the facility staff failed to follow therapeutic diets for one Resident (Resident #45) in the survey sample of 62 residents. The findings include: For Resident #45 the meals served to the Resident on 6-4-24, 6-5-24, and 6-6-24, were not gluten free. Resident #45, was admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. The Resident was also coded as requiring extensive dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. On 6-4-24 at 12:00 noon, Resident #45 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that I didn't get lunch or breakfast today, but someone is getting me some soup now. At that time the dining services director entered the room with a tray which contained 1/2 cup scoop of canned tuna unaltered, 1 cup of clear broth, 2 packages of saltine crackers with 2 crackers in each package, 1 cup of grapes, and a clear plastic water glass with 120 milliliters of iced tea. The dining services director stated I don't know how her meal ticket didn't get printed today, but this will help, she loves tuna. The Resident agreed that she did love tuna. On 6-4-24 At 12:15 pm the surveyor followed the Dining Services Director (DSD) back to the kitchen and received the meal tray tickets for that day. The tickets listed for breakfast that morning she should have received oatmeal, and for lunch spaghetti and meat balls. The (DSD) was asked why the Resident would receive oatmeal, crackers, and pasta for all 3 meals that day when she was gluten intolerant. The DSD stated someone made a mistake. On 6-5-24, at lunchtime the Resident was noted to have fried rice for lunch with soy sauce, and stewed tomatoes with bread in them. She stated she got oatmeal again this morning, all of which contained gluten. The meal tickets were again requested and the items were plainly printed on the tray ticket as observed during meals. On 6-6-24 at lunch the Resident was again visited and her meal ticket obtained from the tray itself. The ticket read Ground baked ham, orange twist, collard greens, roasted red potatoes, whole milk, hot coffee or tea. The ground baked ham and collards were the only thing on the tray included on the menu. Instead the Resident had mashed potatoes, peach cobbler, and iced tea 120 milliliters. The cobbler contained gluten. The meals which were served to the Resident were not what the menu planned, nor what the Resident's therapeutic diet required, and there was only one 4 ounce drink on each tray observed. All meal tickets documented Allergies: Gluten. On 6-6-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. the Administrator stated there should be at least 2 drinks on every tray, and the menu should be followed. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, and staff interviews, the facility staff failed to ensure residents which desires a snack at bedtime received a bedtime snack for three of 62 residents (Resident #21, 2, and 37), in the survey sample. The findings included: 1. Resident #21 was originally admitted to the facility on [DATE] after an acute hospital stay. The admission diagnoses included hemiplegia and hemiparesis, muscle weakness, type 2 diabetes with hyperglycemia, and depression. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/9/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. During the Resident Council Meeting on 6/5/24 at 11:00 AM Resident #21 stated that snacks were not provided to residents at bedtime. Resident #21 also stated that she would like a snack at bedtime if the facility offered a snack to the residents. 2. Resident #2 was originally admitted to the facility 6/2/21 after an acute care hospital stay. The admission diagnoses included muscle weakness, major depressive disorder, hyperlipidemia, hypothyroidism, lymphedema, and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/5/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact. During the Resident Council Meeting on 6/5/24 at 11:00 AM Resident #2 stated that she has never been offered snacks at bedtime. Resident #21 also stated that if the residents would like snacks, the residents have to buy snacks at the General Store. 3. Resident #37 was originally admitted to the facility 3/28/24 after an acute care hospital stay. The admission diagnoses included chronic obstructive pulmonary disease, muscle weakness, hypotension, wernicke's encephalopathy, and alcohol abuse. The Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/1/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #37's cognitive abilities for daily decision making were intact. During the Resident Council Meeting on 6/5/24 at 11:00 AM Resident #37 stated that she has never been offered snacks at bedtime or in between meals. Resident #37 also stated that she desires snacks in between meals and at bedtime. On 6/6/24 at 3:51 PM an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that she cannot verify that snacks are available for the residents in between each meal or when the residents request a snack. CNA #1 also stated that she knows that not all of the residents are receiving snacks due to the other CNA's not passing out the snacks to the residents. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. 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 observation, interview, and facility documentation the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food safety for the facility. The findings included: For the facility in general, the facility staff failed wear beard guard while in kitchen, and also failed to properly store teriyaki sauce. On 6/4/24 at 11:45 -Other Employee 15 observed without beard guard in kitchen. Employee 15 was asked was he supposed to have on a beard guard, and he stated that he was supposed to. When asked why he was not wearing it he stated that he forgot. On 6/5/24 at 9:00 AM - Other Employee 15 again was observed without beard guard in kitchen. When asked a second time, the mployee stated that he forgot. On 6/5/24 at 9:05 AM - Interview with the Dietary Manager who stated it is our policy that all staff wear the appropriate hair net and beard guards while inside the kitchen area. At the end of the day the dietary manager brought the policy for Staff Attire excerpts are as follows: Policy Statement: It is the center policy that all Dining Services employees wear approved attire for the performance of their duties. 1. The Dining Services Director ensures that all staff members have their hair off the shoulders, confined in a hair net or cap and facial hair properly restrained. On 6/4/24 at approximately 12:00 PM observed large half empty bottle of teriyaki sauce in the refrigerator available for use. The bottle of teriyaki sauce had 1/24 written in black marker. The dietary manager was asked what the date 1/24 indicated and she stated it was the opened on date. When asked how long this teriyaki sauce can be stored in the refrigerator after opening, she stated that she would check her sheet from the food vender. When she obtained the sheet, she stated that it's good for 1 year. Dietary manager provided surveyor a copy of the food vender sheet. Upon the surveyor reading the food vendor sheet it revealed sauce is good for 1 month in the refrigerator after opening and 1 year in dry storage unopened. PER manufacturer website: https://kikkomanusa.com/foodservice/faqs: While we recommend our regular soy sauces be refrigerated for quality, our less sodium soy sauces and other sauces should be refrigerated after opening. For the freshest tasting sauce, we recommend using the sauces within one month of opening. On 6/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided prior to survey exit.

Based on staff interviews, the facility staff failed to obtain agreements for dental services and optometry services. The findings included: On 6/12/24 at 10:55 AM an interview was conducted with the Corporate Nurse Consultant and the Administrator. The Corporate Nurse Consultant and the Administrator stated that the facility did not have agreements for outside resources regarding dental services and optometry services. On 6/13/24 at 11:45 AM an interview was conducted with the Corporate Nurse Consultant and the Administrator. The Corporate Nurse Consultant stated that there was no local dentist to accommodate any residents who required stretcher transport. The Corporate Nurse Consultant also stated that if a resident requires glasses the facility will send the resident to the VA (Veterans Administration) Hospital. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. 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 staff interviews, the facility staff failed to obtain a transfer agreement with a hospital to transfer residents from the facility to a hospital when deemed medically appropriate. The findings included: On 6/12/24 at 11:05 AM an interview was conducted with the Corporate Nurse Consultant and the Regional [NAME] President of Operations. The Corporate Nurse Consultant and the Regional [NAME] President of Operations stated that the facility does not have a transfer agreement with a hospital to transfer residents from the facility to a hospital when deemed medically appropriate. The Regional [NAME] President of Operations also stated that no hospital will sign a contract with the facility. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. 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** 2. For Resident # 10, the facility staff failed to provide dignity related to the care of an indwelling urinary catheter (Foley brand name). Resident # 10 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Urinary Tract Infections, Aphasia, Muscle Weakness, Need for Assistance with Personal Care, Presence of Coronary Angioplasty Implant, Anemia, and Epilepsy. Resident #10's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 10 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 7 of 15 possible points on a brief interview for mental status (BIMS), indicating mild to moderate cognitive impairment. The resident was coded as indwelling catheter always incontinent of bladder and frequently incontinent bowel. During an initial tour on 6/4/2024 at 11:45 a.m., Resident # 10 was observed in the hall sitting in a wheel chair with his foley catheter bag visible with dark amber substance in the foley collection bag and the tubing hanging near the floor. Nursing staff was observed in the hallway during the initial tour. Review of Resident #10's physician orders revealed: that the resident has a Foley (brand name) Catheter. The Foley anchor should be changed each week, and Resident should have a leg bag during waking hours. On 6/5/2024, the Director of Nursing (DON), and Administrator were interviewed and asked what their expectation for foley care for this resident. They stated the indwelling urinary catheter should have a leg bag, bag anchor and cover for privacy and dignity. The Corporate Nurse Consultant stated the facility did not have a policy related to provision of indwelling catheter covers/bags to maintain the resident's dignity. On 5/13/2024 and 5/14/2024 during the end of day debriefings, the Administrator, and the DON (Director of Nursing) were notified the above findings. No further information was provided by the facility prior to survey exit. Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain the self esteem/dignity of two resident (Resident # 5 and #10) in survey sample of 62 residents. The findings included: 1. For Resident # 5, the facility staff did not provide a dignified experience regarding incontinence care. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. During an interview on 6/4/2024 at 11:45 a.m., Resident # 4 stated the staff often did not provide incontinence care and she was left soiled for extended periods of time. The room had a pungent odor of urine and feces. Dark brownish colored liquid substance was observed on the bottom sheet with the line of demarcation reaching to level of Resident # 5's hips. The dark substance was noted on the bedspread and top sheet as well. The room was very foul smelling. On 6/4/2024 at 12:10 p.m., Licensed Practical Nurse-1 entered Resident # 5's room and obtained a finger stick blood sugar. LPN-1 was accompanied by a student nurse who stated she was in orientation. LPN-1 and the student nurse did not comment about the pungent odor in the room nor about the brown liquid substance that was evident on the bed sheets and linen. The nurse removed the lid on the lunch tray, Resident # 5 looked at the food and stated she did not want to eat the food. She said it did not smell good and she did not want an alternate meal. LPN-1 stated that Resident # 5 often ordered food from outside restaurants. Resident # 5 stated she did not want any restaurant food either. On 6/4/2024 at 1:15 p.m., Resident # 5 was observed still lying in bed. The room still had the pungent odor of urine and feces. The line of demarcation of the brownish colored liquid was creeping higher up the sheets to approximately the waist level. On 6/4/2024 at 1:45 p.m. and 2:15 p.m , there were observations of Resident # 5 still lying in bed with dark brown liquid stains on the sheets which had increased in size to reach to the middle of Resident # 5's back. There was a pungent odor of urine and feces in the room. During an interview on 6/4/2024 at 2:15 p.m., Resident # 5 stated they haven't changed me yet. They haven't done it since early this morning. Resident # 5 stated she needed to be changed. There were no nursing staff observed in the hallway. On 6/4/2024 at 2:19 p.m., the Corporate Nurse Consultant was asked to come to Resident # 5's room. The Corporate Nurse Consultant came to the room and immediately stated it was evident that Resident # 5 had not had incontinence care for an extended period of time. The room reeked of urine and feces. There were lines of demarcation indicating the urine and feces had crept up higher at different times. The Corporate Nurse Consultant stated she would get someone to provide are immediately. On 6/4/2024 at 2:30 p.m., Resident # 5's door was closed. One Certified Nursing Assistant was observed coming out of Resident # 5's room carrying two clear bags of soiled linen. Feces and urine stains could be visualized on the linens. The Certified Nursing Assistant was asked what she was doing. She stated she had just helped the other CNAs provide incontinence care to Resident # 5. She stated the resident had been incontinent of both urine and feces and all of the linens were soiled. The odor was pungent. She stated incontinence care should be provided every two hours and as needed. She stated she did not know why incontinence care had not been provided earlier. Review of Resident #5's physician orders, Medication and treatment administration records (MAR's/TAR's), Care plan, and progress notes indicated that the Resident suffered from moisture associated dermatitis (MASD) and had a history of a pressure ulcer on the sacrum. On 6/4/2024, the Director of Nursing (DON), and Administrator were interviewed and asked what their expectation for toileting and incontinence care timing was for this Resident. They stated every 2 hours, and as needed, and that the care must be documented after care. Certified Nursing Assistants (CNA's) were interviewed on all three units during survey, and indicated residents should be checked at least every 2 hours and as needed for incontinence care. On 6/5/2024 at 9:20 a.m., an interview was conducted with Certified Nursing Assistant-3 who stated they turn and reposition residents every 2 hours but sometimes every hour depending on the needs of the resident. CNA-3 stated incontinence care should be given every hour or even 30 minutes if needed. She also stated showers should be given at least twice a week and more often if needed or if the resident requests one. Resident # 5's point of care documentation by primary care staff to indicate care that was given every day was reviewed. The facility instituted 8 hour working shifts for staff, and those 3 shifts were 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. The records indicated that for the months of April 2024, May 2024 and June 2024, Resident # 5 was totally dependent on staff for toileting and incontinence care. The Corporate Nurse Consultant stated the facility did not have a policy on ADL (Activities of Daily Living) care. She stated the expectation was that care would be provided approximately every 2 hours every shift and PRN (as needed). She stated failure to provide timely incontinence care did not show treatment with dignity. Interviews were conducted with staff members by the survey team. Staff members stated that the expectation was to give incontinence care immediately after every incontinent episode. Resident # 5 was not afforded timely incontinence care and was not shown dignity and respect. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debriefing on 6/5/2024. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #27 the facility staff failed to follow physicians orders by not ensuring Resident #27 received her necessary wound care treatments. Resident #27 was originally admitted to the facility 11/18/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Pressure Ulcer of the Right Ankle and Peripheral Vascular Disease. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/05/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goal) Requires set up and or clean up assistance with eating, oral hygiene and personal hygiene. Requiring substantial/maximal assistance with toileting hygiene and lower body dressing. In Section M (Skin Conditions) Resident is coded as being at risk for Pressure Ulcers. Resident is coded as not having any unhealed Pressure Ulcers. Resident is coded as having 3 Venous and Arterial Ulcers. The Care Plan dated 11/22/22 and revised on 7/23/23 read that Resident #27 was at risk for Pressure Ulcers related to weakness, impaired mobility and incontinence, Right hemiparesis status post (s/p) Cerebral Vascular Accident (CVA). The Goal for Resident #27 is that the resident will not have a skin impairment thru the review period. assess resident for risk of skin breakdown, assist the resident to turn and reposition often, Keep skin clean and dry as possible. The Medication Administration Record (MAR) for May and June 2024 Solosite Wound Gel External Gel (Wound Dressings) Apply to buttocks, R lateral ankle topically every night shift every other day for Stage 4 pressure ulcer -Order Date 05/21/2024 9:41 AM -D/C Date 06/06/2024 10:24 AM. Missed treatment on 6/04/24. WOUND CARE: Buttocks, right lateral ankle: Cleanse and pat dry. Apply scant amount of Solosite to wound and cover with foam dressing. Change Q2 days or PRN for soiling. every night shift every other day -Order Date 05/21/2024 9:38 AM -D/C Date 06/06/2024 10:18 AM. Missed treatment on 6/04/24. WOUND CARE: Please apply betadine-soaked gauze, 4x4s, Kerlix, and a light ACE bandage to right foot every other day every night shift every other day -Order Date 05/21/2024 9:47 AM -D/C Date 06/06/2024 10:13 AM., Missed Treatment on 6/04/24. LEFT BUTTOCK - Cleanse with wound cleanser, pat dry, apply hydrogel, cover with bordered gauze. every night shift for pressure stage 3 wound -Order Date05/09/2024 1315 -D/C Date 05/21/2024 0923. Missed treatments: 5/10/24, 5/12/24, 5/15/24, 5/16/24. Right Lateral ankle: Cleanse with normal saline, Pat dry, skin prep to surrounding tissue, Manuka HD alginate, Honey fiber to wound bed, Bordered foam, NO ACE BANDAGE OR KERLIXNO COMPRESSION OF ANYKIND one time a day for WOUND -Order Date 02/27/2024 4:30 PM. -D/C Date 05/21/2024 9:22 AM. Missed Treatments. 5/01/24, 5/02/24, 5/08/24. On 6/11/24 at approximately 2:55 PM., an interview was conducted with the Director of Nursing (DON) concerning skin assessments and missed wound care treatments. The DON said that it is expected that the nurses perform skin assessments and carry out wound care treatments on their residents. The DON also mentioned that if the CNAs notice any new areas on the residents' skin, they will inform the nurse. On 6/12/24 at approximately 11:00 AM., an interview was conducted with Certified Nursing Assistant (CNA #6) concerning Resident #27. CNA #6 said that the resident didn't have any skin issues in January. On 6/12/24 at approximately 1:35 pm., an interview was conducted with the Wound Care Nurse Practitioner (WCNP). The WCNP said that she was not aware of any missed wound care treatments. On 06/13/24 at approximately 2:00 p.m., 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 resident interview, staff interview and clinical record review, the facility staff failed to provide care and services in accordance with professional standards for three resident (Resident #5, #173 and #27) in a survey sample of 62 residents. The findings included: 1. For Resident # 5, facility staff failed to administer, and/or document medications and treatments as administered, as ordered by the physician on several dates including but not limited to: 5/5/2024, 5/13/2024 and 5/30/2024. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. Review of Resident #5's clinical record was conducted on 6/4/2024-6/7/2024. Review of the physician orders and medication administration documentation revealed the following: Review of the facility policy entitled, Administering Medications, revised April 2019, heading Policy read, Medications are administered in a safe and timely manner, and as prescribed and subheading Policy Interpretation and Implementation, item 4 read, Medications are administered in accordance with prescriber's orders, including any required time frame. Review of the May 2024 Medication Administration Record revealed several medications that were not administered as ordered by the physician. The medications included but were not limited to: Amlodipine 10 mg (milligrams) - Give 1 tablet by mouth in the evening for Hypertension Order Date- 12/08/2023 1601 Scheduled 8 p.m. not given 5/5/2024, 5/13/2024 and 5/30/2024 at 8 p.m. Nortriptyline Oral Capsule 10 milligrams-Give 20 mg by mouth at bedtime related to Major Depressive Disorder Order Date-11/1/2023 -scheduled at 9:00 p.m. not given 5/5/2024 and 5/30/2024 at 9 p.m. Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (units per milliliter) (Insulin Glargine) Inject 40 unit subcutaneously at bedtime for Diabetes IF PT (patient) REFUSES, DOCUMENT AND NOTIFY PROVIDER. -Order Date-04/05/2024 1648 not given at 9 p.m. on 5/5/2024, 5/13/2024, 5/30/2024 Melatonin Tablet 5 mg-Give 1 tablet by mouth at bedtime for insomnia -Order Date- 05/19/2023 1040 Not given 9 p.m. on 5/5/2024, 5/30/2024 Trazodone HCl ( Tablet 50 MG-Give 1 tablet by mouth at bedtime for insomnia GDR (gradual dose reduction) -Order Date- 03/24/2023 1116 Not given 9 p.m. on 5/5/2024, 5/30/2024 Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for HTN Hold if SBP (systolic blood pressure) < (greater than)100 HR (heart rate) < (less than) 50 -Order Date- 01/10/2024 1624 Not given 9 p.m. on 5/5/2024, 5/30/2024 Eliquis Tablet 5 MG (Apixaban)-Give 1 tablet by mouth two times a day related to personal history of other venous thrombosis and embolism -Order Date- 01/10/2024 1621 Not given 9 p.m. on 5/5/2024, 5/30/2024 Review of the May 2024 Treatment Administration Record revealed missing documentation of treatments to include but not limited to: Skin care-sacrum, under bilateral breast, bilateral axilla, abdominal fold, cleanse area with soap and water, pat dry, apply skin prep to surrounding tissues, ketoconazole Cream 2% and petroleum-based barrier cream together and leave open to air. every day and evening shift for Treatment -Order Date-05/03/2024 1339 not administered on 5/5/2024 day and evening, 5/8/2024 day and evening, 5/9/2024 evening, 5/13/2024 evening and 5/17/2024 day shift. Guidance for nursing standards for the administration of medication provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705 stated Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. Resident 5's care plan was reviewed and revealed a care plan that instructed to administer medications and treatments as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medications had been omitted, nor that the doctor was made aware of the omissions. On 6/5/2024 at 10:20 a.m., an interview was conducted with Licensed Practical Nurse-1 who stated the expectation was for nurses to administer medications and treatments as ordered by the physician. She stated that nurses should document immediately after administration of medications and treatments. On 6/6/2024 at 2:25 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for the staff to administer medications and treatments as ordered by the physician. On 6/6/2024, during the end of day debriefing with all surveyors, the Administrator and Corporate Nurse Consultant were made aware of the failure of staff to administer medications as ordered. No further information was provided. 2. The facility staff failed to administer ophthalmic (eye) medications to Resident #173 as ordered. Resident #173 was originally admitted to the facility 6/3/24 after an acute care hospital stay. The resident's diagnoses included alcohol abuse and glaucoma. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 6/3/24. The tool revealed at number 1. Cognitive state that the resident was oriented to person and place, at number 8. Gastrointestinal, the resident was continent of bowels, at number 9. Genitourinary, the resident was continent of bladder, at number 12.GG that the resident required set-up assistance with eating and oral care. The resident was not assessed for toileting hygiene, to move from sitting on side of bed to lying flat on the bed, to come to a standing position from sitting in a chair, and with transfers. An interview was conducted with the resident on 6/10/24 at approximately 1:40 P.M. Resident #173 stated he had not received his eye drops since admission to the facility. The resident further stated that his sister administered his ophthalmic drops when he was home. The resident also stated he had not experienced blurred vision, burning, itching, or a feeling as if something was his eye since he was not being administered the ophthalmic drops. The resident asked, when would he receive the ophthalmic drops. Resident #173 had the following ophthalmic orders dated 6/3/24; Latanoprost Ophthalmic Solution 0.005 % - Instill 1 drop in both eyes at bedtime and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % - Instill 1 drop in both eyes two times a day. During the 6/10/24, medication storage task of the Hall 3 medication cart, the Dorzolamide HCl-Timolol Mal ophthalmic drops were not on the medication cart. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 6/10/24 at approximately 1:07 PM. LPN #6 stated she administered the resident's Dorzolamide HCl-Timolol Mal ophthalmic drops that morning and she threw the bottle in the trash afterwards because they were drops sent over from the hospital. The Medication administration Record (MAR) revealed on 6/6, 6/9 and 6/10 the 9:00 P. M., medication was documented as waiting for pharmacy and on order. A note was also written for the medication on 6/12/24. It stated Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 %. Instill 1 drop in both eyes two times a day for one time hold order per the Physician's Assistant because the family was providing the supplies and the resident is his own Responsible Party. An interview was conducted with the Pharmacist on 6/1/24 at 2:30 PM. The Pharmacist stated the Dorzolamide HCl-Timolol Mal ophthalmic drops were delivered to the facility on 6/4/24 and signed as received by Registered Nurse (RN) #4. The location of the ophthalmic drops which were delivered and signed as delivered was not determined by the facility's staff. On 6/10/24 at 12:40 PM during the medication storage task of the medication refrigerator, a sealed unopened bottle of Latanoprost Ophthalmic Solution 0.005 % was observed in the refrigerator. This ophthalmic drop was scheduled to given each night at bedtime. The bedtime dose was signed off as administered each night except 6/3, 6/6, 6/7 and 6/9. The progress notes regarding the medication read waiting for pharmacy, med not available, on order. At approximately 4:50 PM on 6/12/24 the sealed unopened bottle of Latanoprost Ophthalmic Solution 0.005 % was validated in the refrigerator by Corporate Nurse #1. They were still not in use. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator, and two Corporate Nurse Consultants. They had no new information regarding the missing bottle of Dorzolamide HCl-Timolol Mal ophthalmic drops or comments on why the Latanoprost Ophthalmic Solution 0.005 % remained in the refrigerator unused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #26's admission activity assessment had not been completed to identify activity preferences. Resident #26 was originally admitted to the facility 9/5/23 after an acute care hospital stay. The current diagnoses included hyperlipidemia, major depressive disorder, essential hypertension, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/13/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making were intact. On 6/12/24 at 2:55 PM an interview was conducted with Resident #26. Resident #26 stated that she rarely participates in activities due to no staff member's asking her if she would like to participate in the facilities activities. Resident #26 also stated that she requires to be transferred in a wheelchair to attend the activities and no staff member will take her to the activities. A review of Resident #26's clinical record revealed that an activity admission assessment was not completed. On 6/12/24 at 3:35 PM an interview was conducted with the Corporate Nurse Consultant. The Corporate Nurse Consultant stated that an activity admission assessment was not completed for Resident #26. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. 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 observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment and care plan by a qualified Activities Professional for 4 of 62 residents (Resident #1, 170, 9, and 26), in the survey sample. The findings included: 1. On 6/12/24 at approximately 1:15 PM, Resident #1 was identified as an individual who could benefit from one to on or frequent short activities throughout the day. Resident #1 was originally admitted to the facility on [DATE] and he had never been discharged from the facility. The resident's diagnoses included dementia with behavioral disturbances. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/9/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 06 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired. Resident #1 was observed to stay in bed most of the day and to get up and roam the hallways in the afternoons. On 6/6/24 at approximately 4:35 PM an interview was conducted with Licensed Practical Nurse (LPN) #20. LPN #20 stated that the resident had been involved in altercations with other residents, wanders in others rooms in the evenings and is known to curse other residents and staff. LPN #20 also stated the resident is not redirectable. LPN #20 stated she was unaware that according to the resident's activity assessment that the resident enjoyed reading the newspaper, watching the news and car races but she would initiate the interventions going forward. The activity assessment dated [DATE] identified the resident as alert and oriented times for and identified the resident as a she, therefore it was not clear if this assessment was for the Resident #1. The resident's comprehensive person-centered care plan did not included an activities care plan. An interview was conducted with the uncertified/unregistered Activities Director (AD) on 6/11/24 at approximately 11:00 AM. The AD stated that Resident #1 does not participate in activities and if he happens to come into an activity he does not stay very long, never for the duration of the activity. 2. On 6/13/24 at approximately 1:30 PM, Resident #170 was observed in bed lying on her right side as she had been on 6/4/24 through 6/7/24 and 6/10/24 through 6/11/24. Resident #170 was identified as an individual who could benefit from activities. Resident #170 was originally admitted to the facility on [DATE] and she had never been discharged from the facility. The resident's diagnoses included afib, congestive heart failure and advanced stage pressure ulcers. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 5/29/24. The tool revealed the resident was oriented to person, place, time and situation. During all interactions with the resident on 6/4/24 through 6/12/24 the resident was oriented in all four spheres. The resident's activity assessment dated [DATE] read the resident enjoyed all kinds of animals and news, as well as gardening, sewing and groups of people. On 6/4/24 at approximately 3:30 PM an interview was conducted with Resident #170. The resident lacked emotions and had to be asked questions to express herself. The resident was absent of a smile, talked about going home but initiated nothing to assist herself out of the current situation. On 6/12/24 she was out of bed sitting in a chair for the first time and only interacted when she was encouraged. The resident did not attend activities on 6/12/24. The resident's comprehensive person-centered care plan had not been developed and there was not an activities care plan included with the problems developed. An interview was conducted with the uncertified/unregistered Activities Director (AD) on 6/11/24 at approximately 11:00 AM. The AD stated that Resident #170 had not participated in group activities and she was not receiving one to one activities. 3. Resident #9 was observed in her room in bed much of the survey. The resident was not engaged in any type of activities to benefit from person-centered activities. Resident #9 was originally admitted to the facility 11/19/2020 and was last discharged from the facility 5/11/22 and returned to the facility 5/16/22. The resident's current diagnoses included depression and venous ulcers of bilateral lower extremities. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/25/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. The resident's last activities assessments in the clinical record was dated 4/16/23. It read the resident was activities interest including participating in painting, cards, reading mysteries, listening to oldies/country music, watching news, soap operas, game shows, word search, and socializing with peers. The comprehensive person-centered care plan was last revised on 12/28/2023. An interview was conducted with the uncertified/unregistered Activities Director (AD) on 6/11/24 at approximately 11:00 AM. The AD stated she had received some training to the position from an AD from a sister facility but she had not completed a certification program. The AD further stated the corporate person responsible for the ADs sent information for her to register for the certification program but when she presented the information to the Administrator after completing the registration form the Administrator stated to wait and never got back with her regarding the certification program. The facility's policy titled Activities Programming dated 11/1/23, stated that the recreation department would provide, based on the comprehensive assessment and care plan and the preferences of each resident an ongoing program to support residents in their choice of activities, both facility sponsored group, individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator and two Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #37, the facility staff failed to ensure the resident was safe to smoke and supervised a designated smoking area to prevent injuries to themselves and other surrounding residents. Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE]/2024 with the diagnoses of, but not limited to acute respiratory failure with oxygen deficits, Chronic Obstructive Pulmonary Disease (COPD), low blood pressure, anemia, history of falling and tobacco use. Resident #37's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 06/01/2024 coded Resident #37 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 possible points, indicating cognition intact. The MDS coded Resident #37 as requiring limited assistance with Activities of Daily Living (ADLs), supervision with eating, and limited assistance with toileting. A review of Resident #37 clinical record, including the resident's comprehensive care plan, revealed no evidence of a smoking safety assessment, or smoking agreement. On 6/4/24 at approximately 12:55 p.m., during an initial tour of the facility, Resident #37 was observed alert and unsupervised smoking sitting in a wheelchair in front of the building. On 6/4/24 at 3:50 p.m. Resident #37 was observed smoking unsupervised sitting in a wheelchair at the gazebo area at the back of the facility. On 6/4/24 at 2:20 p.m., the Administrator and Director of Nursing (DON) were interviewed and asked if there were any smoking residents in the building. The Administrator said there were none. When asked what was expected if there was a smoking resident, the Administrator responded that they would complete a Smoking Safety Screening, and have the resident sign a Smoking Agreement. No further information was provided before the survey's exit. Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure residents environment remained as free of accident hazards as is possible for residents that used the dining room and for a resident who smoked, Resident #37. The findings included: 1. The facility staff failed to ensure chemicals were kept away from unattended residents reach, and out of public areas. On 6/4/24 at approximately 1:00 PM a bottle observation was made of a half full spray bottle of Wallpaper Remover sitting on the table on the right side of the dining room near the wall. Other Employee 3 was in the dining room and was asked if the bottle was something she was using. Other Employee #3 stated that she worked in the laundry and that it was not something housekeeping would generally use. On 6/4/24 at approximately 1:15 PM an interview was conducted with the maintenance director who stated he had not seen this chemical before and was unaware of who might be using it. He stated that he did not have an MSDS (Materials Safety Data Sheet) on the chemical as it is something he does not use. When asked the danger of having a chemical like this around the residents he stated that a resident could accidentally spray it on themselves or ingest it. On 6/5/24 at approximately 1:30 PM an interview was conducted with the Administrator who was asked about the chemical in the building, and she stated that she was unaware of it being in the dining room and unaware of anyone using it. When asked the danger of having a chemical like this in the open dining room, unsecured she stated there is a potential for unintentional ingestion or spraying in the eyes or on skin of the resident. On 6/12/24 at the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents receive sufficient fluid intake to maintain proper hydration, and maintain acceptable parameters of nutritional status, and was offered a therapeutic diet when needed for 2 (R #258 and #13) residents in a survey sample of 62 residents. The findings included: 1. For Resident #258, the facility staff failed to ensure the resident was provided a diet that he could eat to maintain adequate nutritional status. Resident #258 was admitted to the facility on [DATE] with diagnoses that included but were not limited to malnutrition, dementia, weakness, abnormality of gait, and history of falls. On 6/5/24 observation made of Resident #258's lunch tray, resident only ate pudding and applesauce. On 6/6/24 observation of breakfast tray Resident #258 ate only hot cereal. On 6/7/24 at approximately 12:15 PM, an observation was made of Resident #258 in his room with his family at his bedside. An interview was conducted with Resident #258's family member who stated that Resident #258 does not eat much because his has no teeth. The family elaborated by saying he has dentures but does not use them because they do not fit right. A review of Resident #258's tray ticket revealed he was on a regular diet with regular texture and thin liquids. 6/7/24 at 4:00 PM a review of the clinical record revealed the following diet order: 5/25/24 Regular diet, Regular texture, Thin Liquids consistency. A review of the clinical record revealed a Malnutrition Universal Screening Tool (MUST) was completed on 5/30/24 and the results were as follows: Patient: [Name redacted] Category: High Risk (Treat) Description: admission Score: 2.0 Date: 5/30/2024 11:24 The order was place for Med Pass 90 ml a day for prevention of malnutrition. On 6/10/24 an interview was conducted with the Nutritionist who stated she had not yet seen Resident #258 and was unaware of his edentulous status. She stated that some people do better than others without teeth so she would evaluate him later on that day. A review of the clinical record revealed that on admission Resident #258 weighed 122.2 lbs. On 6/10/24 CNA #'s 1, 5 and 6 accompanied the surveyor to check Resident #258's weight. Resident #258 weighed 116 pounds which was a 5.07 % weight loss since his admission (16 days), this represented a significant weight loss. 6/10/24 at 1:23 PM Note Text: RD was made aware that rsd (sic) has not been consuming much of his meals. RD visited w/ rsd who appears to have impaired dentition. RD spoke w/ rsd's RP (son) who reports he has been visiting the facility to assist rsd with consuming his meals. Son has noticed rsd has trouble with some of the bread items with his meals. RD asked son if he thinks rsd would benefit from some softer food items to which son stated yes. RD spoke w/ DOR about possible SLP screen r/t most recent BIMS of 7. Will downgrade diet to Dysphagia Advanced and refer to therapy for possible SLP evaluation. Rsd continues on Medplus 2.0 supplement Q Day [every day] for additional nutrition w/ good acceptance per staff. Currently awaiting an updated weight at this time. Will cont. to monitor. On 6/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #13, the facility staff failed to ensure sufficient hydration and to honor resident's choice for fluids. On 6/4/24 at approximately 2:00 PM an interview was conducted with Resident #13 who stated What I would like to get is some ice water. I can never seem to get them to keep this cup filled. Resident pointed to large Styrofoam cup on the bedside table. When asked if she tried ringing her call bell she stated, I would if I could reach it, they keep it wrapped around my rail and its above my head out of reach I cannot get to it like that. When asked if she had told the staff that it is a problem when they wrap cords around the rail, she stated that she had told them, but they continued to do it anyway. On 6/4/24 at 11:45 a.m., during initial tour of the facility Resident #8 was interviewed. The resident was sitting in bed consuming lunch and complained to the surveyor, Everything is fine here as long as they fill my water container with ice. I just can't drink it room temperature, and they don't fill it but one time a day some days, that's my only problem. The water pitcher was observed to have no ice in it and held approximately 1 quart of water when full. It was found to be half full of room temperature water. On 6/5/24 at approximately 10:30 a.m., Resident # 13's cup was empty of iced water and once again the call bell was observed to be out of her reach. On 6/6/24 at approximately 3:00 p.m., Resident #13 was out of iced water again and the call bell once again was out of her reach. At 3:05 PM on 6/6/24, an interview was conducted with CNA #3 who was asked why call bells would be wrapped around a bed rail, CNA #3 stated the staff sometimes did this to keep the call bell from falling off of the bed and onto the floor, some residents prefer the call bell to be wrapped around the rail so they can reach it. CNA #3 was asked if a call bell should be in the resident's reach at all times, CNA #3 stated that it should always be in reach of the Resident so in case they have an emergency they can reach the nurse. CNA #3 was then asked to view the call bell in Resident #13's room and see if there was a problem with the resident reaching it. CNA #3 came out of the room and stated it was up too high wrapped around the rail and she could not reach it. CNA #3 stated I fixed it for her know I am going to get her some iced water. On 6/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #31, the facility staff failed to change Oxygen Humidifier Tubing per policy every 7 days. Resident #31 was originally admitted to the facility on [DATE]. The Resident went out to the hospital on 2/04/22 and returned on 04/15/22 to the facility with diagnoses including but not limited to, unspecified convulsions, aphasia, muscle weakness, acute respiratory failure with hypoxia, muscle weakness, essential hypertension, and dependence on supplemental oxygen. Resident #31's most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Reference Date (ARD) of 4-21-24. The MDS coded Resident #31 with a BIMS (Brief Interview for Mental Status) score of 6 out of 15 possible points, indicating severe cognitive impairment. The MDS coded Resident #31 as requiring extensive assistance with Activities of Daily Living (ADL's) and total dependent for toileting. Review of the care plan (dated 4-15-24) revealed: The resident is at risk for respiratory complications, secondary to (nothing listed). Interventions: Administer oxygen as ordered. Assess oxygen saturation and vitals needed. On 6/4/2024, at approximately 12:55 PM, during the initial tour of the facility, it was observed that Resident #31's oxygen humidification tubing was dated 05/26/2024. An interview was conducted on 6-4-24 at 12:55 PM, with Resident #31 and the resident's family member. The family member was asked if the residents oxygen tubing changed weekly. Both Resident #31 and the family member stated, The oxygen tubing is not changed weekly. Review of physician's orders revealed that the following oxygen orders for Resident #31: Ordered 5/20/24, oxygen therapy at 2 liters per minute via nasal cannula. Ordered 5/20/24, oxygen tubing change weekly on 11-7 shift (Sundays). On 6/5/24 at approximately at 11:00 AM, LPN (licensed practical nurse) #1 was interviewed and asked what was expected regarding changing residents' oxygen tubing and supplies. LPN #1 stated that oxygen settings, change orders and care should be administered per physician's order and documented in the Medical Administration Record (MAR) and Treatment Administration Record (TAR). The facility oxygen use policy was reviewed and indicated the following: Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per provider's orders and in accordance with standards of practice. Monitor and record saturation levels and vital signs as indicated, or by provider's order. Document oxygen delivery flow rate, method of delivery, date and time, saturation levels if indicated, in the electronic medical record. Document oxygen saturation level/and or vital signs in the electronic medical record as indicated, and any unusual findings and follow-up interventions including provider and responsible party notification. On 6/04/24, at approximately 4:00 PM, the Administrator and Corporate RN were made aware of the findings regarding the lack of care regarding Resident #31's oxygen tubing. No further Information was provided before survey exit. Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care consistent with professional standards of practice for 3 Residents (R #23, R #258 and R# 31) in a survey sample of 62 Residents. The findings included: 1. For Resident # 23 the facility failed to ensure the Bi-Pap was placed on the resident as ordered by physician. Resident #23 was admitted to the facility on [DATE] with diagnoses that include but are not limited to hypertension, Paroxysmal Atrial Fibrillation, adult failure to thrive, history of Malignant Neoplasm of Prostate Protein -Calorie malnutrition, chronic respiratory failure with hypoxia, dependence on enabling machines or devices, pressure ulcers and dysphagia. On 6/10/24 at 11:40 AM Resident was observed in bed head of bed elevated, wearing hospital gown awake watching television. Resident # 23 was observed to have a Bi-Pap machine at the bedside however there was no date on tubing and there was no storage bag in site tubing was draped across the bedside table. When asked about the Bi-Pap the Resident stated he did not use it much. When asked why he said, They don't put it on me anymore. On 6/10/24 a review of the clinical record revealed that Resident #23 was admitted from the hospital with orders to wear the Bi-Pap at the hospital adjusted setting every night. A review of the physicians orders and the TAR (Treatment Administration Record) revealed the following orders for Bi-Pap: Please place BiPAP on every night at bedtime every evening and night shift -Order Date-05/08/2024 CPAP/BiPAP Oxygen tubing change weekly every evening and night shift -Order Date- 05/17/2024 -D/C Date- 06/05/2024. A review of the clinical record revealed that the BiPAP was on the TAR and marked as NO (not applied) on eve 6 of the 11-evening shifts and 2 of the 11-night shifts were marked as refused, and there no documentation of physician notification of refusal from 6/1/24 - 6/11/24. On 6/10/24 an interview was conducted with the DON who stated that Resident #23 is supposed to be using the Bi-Pap at night she stated that she knew he sometimes refused, however, she stated it should be offered to the resident and documented as refused if the Resident refuses. The DON stated Resident #23 should be encouraged to wear the BiPAP at night and the physician should be notified of repeat refusals. The DON stated she would see that the orders were corrected, and that the Resident was offered the Bi-Pap at night and that the weekly tube changing order be reinstated. On 6/11/24 during the end of day meeting the Administrator was made aware of the concern and no further information was provided 2. For Resident #258 the facility staff failed to change the oxygen tubing as per physician order. Resident #258 was admitted to the facility on [DATE] with diagnoses that included but were not limited to malnutrition, dementia, weakness, abnormality of gait, and history of falls, his most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/31/24 coded him as having a BIMS (Brief Interview of Mental Status) score was 7/15, indicating severe cognitive impairment. On 6/4/24 at 12:30 PM observation was made of Resident #258 in bed with oxygen being administered via oxygen concentrator the tubing was not labeled with a date that it was applied. On 6/5/24 at 10:00 AM the oxygen was observed with no date. On 6/5/24 a review of the MAR revealed that the oxygen tubing was signed off as being replaced on 6/2/24. On 6/6/24 at 2 PM Resident #258 was observed in his bed without the oxygen on the tubing was laying draped across the oxygen concentrator. Resident #258 was asked if he should have the oxygen in place and he stated he only used it when he needed it. On 6/7/24 at approximately 2:00 PM, LPN #2 was asked how frequently the oxygen tubing is changed, she stated that they are done on night shift on Sundays. When asked how I will know if the tubing was actually changed, she stated that the staff will put a date on the tubing. When asked if she could find the date on the tubing she stated, I don't see one. A review of the facility policy for respiratory care revealed the following excerpts: Paragraph 2 Cleaning and Storage in Room 2. Store tubing/masks/yanker, etc. in plastic storage bag when not in use. 3. Tubing / Masks/ yankers, etc. are to be changed weekly and prn. On 6/10/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on staff interviews, and facility documentation, the facility failed to have sufficient nursing staff to ensure resident safety and resident needs are met. The findings included: The facility staff failed to maintain Certified Nursing Assistant (CNA) staffing at sufficient numbers to ensure continuity of care and safety for the residents as documented in the as worked schedules for 5/11/2024-5/13/2024, 5/24/2024-5/31/2024, and 6/4/2024-6/24/2024. On 6/6/24 at 2:00 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the staffing of the units. The HR Director stated that the facility has been short-staffed and are currently supplementing staff with agency staff. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on staff interviews, and facility documentation, the facility staff failed to ensure that licensed nursing staff completed the required competencies necessary to care for residents' needs. The findings included: The facility failed to maintain the required nursing staff competencies necessary to care for residents. A review of the Training Transcripts for 19 licensed staff members revealed that nine (9) of the 19 licensed nursing staff members did not complete the required training courses. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resource (HR) Director who was asked about the licensed nursing staff competency training courses. The HR Director was not able to present evidence that the nine (9) licensed nursing staff had completed the required competency training courses. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey's exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that a Registered Nurse worked at least 8 consecutive hours within 24 hours, 7 days a week. The findings included: The facility failed to ensure that a Registered Nurse (RN) worked at least 8 consecutive hours within 24 hours, 7 days a week. A review of the as worked schedules for 5/11/24-5/13/24, 5/24/24-5/31/24, and 6/4/24-6/24/24, indicated there was no documentation that a Registered Nurse worked for 8 consecutive hours a day, 7 days a week. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about nursing staff RN coverage. The HR Director said that she was aware that an RN was required at least 8 consecutive hours, 7 days a week. The HR Director stated that the facility has been short-staffed and was currently supplementing staff with agency staff. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided prior to the survey's exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that the nurses' aides had performance reviews every 12 months and at least 12 hours of regular in-service education included on the aide's performance review. The findings included: The facility failed to conduct nurse aide performance reviews every 12 months and at least 12 hours of in-service education included on the aide's annual performance review per their hire date. A review of the training transcripts and staff education files revealed that not all nurse aides completed the mandatory in-services education. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the nurse aides' in-service education and stated that the employee files that included performance reviews and in-service records were correct and up to date. She had no additional records to provide for the nurse aides who did not have annual performance reviews with the required training hours. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey's exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for two (2) Residents (Resident #49, and #45) in a survey sample of 62 residents. The findings included: 1. For Resident #49, Facility staff failed to Administer Lovenox (anticoagulant) and Keflex (antibiotic) medication. Resident #49, was admitted to the facility on [DATE], and discharged to the emergency room with an infected wound on 4-19-24. The Resident returned on 4-24-24. Diagnoses included; After care following hip fracture, alzheimers disease, stage 4 sacral pressure sore, hypertension, hypothyroid, stroke, malnutrition, aphasia, dysphagia, and aspiration pneumonia. Resident #49 was a bed bound patient with severe cognitive impairment. Resident #49 was documented as being totally dependant on staff for all activities of daily living such as hygiene, transferring, and bed mobility. The Resident was incontinent of bowel and bladder. The Resident's physician orders were reviewed and revealed orders for anticoagulants and antibiotics. The orders were for the following; 1. Ordered 4-24-24 at 2:59 pm, Lovenox inject 0.4 milliliters subcutaneously one time per day for 20 days. 2. Ordered 5-13-24 at 9:43 am, Cephalexin/Keflex 500 milligrams tablet every 12 hours at 9:00 am, and 9:00 pm, for urinary tract infection for 8 administrations. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April and May of 2024 2024, and revealed the absence of nursing signatures on some occasions, and a signature with the number 5 added to it indicating the medications were not administered. Those follow; Lovenox not administered; 4-25-24, 4-26-24, 5-13-24, 5-14-24, 5-15-24, at which time it was discontinued with only 17 doses given omitting 3 doses. Keflex not administered: 5-15-24 at 9:00 am, and it was discontinued on 9-17-24 after the 9:00 am dose having administered 7 of 8 doses. Nursing medication administration notes do not indicate why the Lovenox and Keflex were not administered as ordered, and why they were omitted. Guidance for the administration of Antibiotics and Anticoagulants is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Antibiotics must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Antibiotics increases the likelihood of MDRO's (multi drug resistant organisms) such as Methycillin Resistant Staphyloccocus Aureus (MRSA), and can result in rebound infections which can be life threatening. National Institutes of Health & Medline.gov; Anticoagulant medication must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Resident #49's care plan was reviewed and revealed a care plan for Anticoagulant medications, however, it was not revised to include a care plan for urinary tract infections and antibiotic use. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 or a 5 on the medication administration record (MAR), that the medication was not administered. Nursing staff further agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks, and withholding antibiotics could cause a rebound infection. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, and that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to ensure medication administration per physician's orders. No further information was provided. 2. For Resident #45, Facility staff failed to Administer Eliquis/Apixaban (anticoagulant) medication. Resident #45, was initially admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. Resident #45 was also coded as requiring extensive dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders from the hospital were reviewed and revealed 2 orders for an anticoagulant. The orders were for the following; 1. 3-23-24 Apixaban (Eliquis) 5 mg (milligram) tablets take 2 tablets by mouth twice (20 mg per day) daily for 12 doses (6 days). Dispense 24 tablets. The original 10 mg dose ordered twice daily for 12 doses (6 days) was only given for 3 days on 3-25-24, 3-26-24, and 3-27-24. The Resident only received once daily 10 mg evening doses on 3-24-24, 3-28-24, and 3-29-24, for a half dose each day. The other 10 mg evening doses were omitted. 2. 3-23-24 Apixaban (Eliquis) 5 mg tablets start 3-29-24 take 1 tablet by mouth twice (10 mg per day) daily for 90 days. Dispense 60 tablets with 2 refills. The Medication and Treatment Administration Records (MAR/TAR) was reviewed for March, April, may, and June 2024, and revealed the absence of nursing signatures on multiple occasions. Those follow; 9:00 am dose - 4-14-24, 4-21-24, 4-25-24. 6:00 pm dose - 3-23-24, 3-24-24, 3-28-24, 3-29-24, 4-7-24, 4-17-24, 6-1-24, and 6-3-24. Nursing medication administration notes do not indicate why the medications were not administered as ordered, and why they were omitted. Guidance for the administration of anticoagulant medication is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Anticoagulant medication must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Resident #45's care plan was reviewed and revealed no care plan revision for anticoagulant drug use for pulmonary embolus, nor assessments for potential bleeding. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 or a 5 on the medication administration record (MAR), that the medication was not administered. Nursing staff further agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, and that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to ensure medication administration per physician's orders. No further information was provided prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure pharmacist reported irregularities to the attending physician, the facility's medical director and the director of nursing, and were acted upon for four (4) of 62 residents (Resident #11, #172, #4 and #25), in the survey sample. The findings included: 1. The facility staff failed to ensure the physician and/or designee received the recommendations from the pharmacy review dated 4/20/24 for Resident #11. Resident #11 was originally admitted to the facility 4/18/24 after an acute care hospital stay. The current diagnoses included type 2 diabetes mellitus, acute bronchitis, hyperlipidemia, depression, muscle weakness, and unspecified dementia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/24/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #11's cognitive abilities for daily decision making were severely impaired. A review of the Consultant Pharmacist Medication Review for Resident #11 dated 4/20/24 at 7:53 PM read: see report for any noted irregularities and/or recommendations. On 6/10/24 at 3:05 PM an interview was conducted with the Corporate Nurse Consultant. The Corporate Nurse Consultant stated that the facility does not have documentation that the Physician and/or designee received the recommendations from the pharmacy review dated 4/20/24 regarding Resident #11. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. 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. 2. For Resident # 172 the facility staff failed to document in the resident's medical record that the identified pharmacy recommendation had been reviewed and any actions taken as a result. On 6/10/24 a review of the clinical record revealed that Resident #172 was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes, hereditary lymphedema, non-pressure wound to left leg, MVA (Motor Vehicle Accident) driver resulting in lacerations with sutures to left lower leg and foot, muscle weakness and abnormal gait. On the morning of 6/10/14 a review of the clinical record was conducted, and it was found that during the month of May, a pharmacy drug regimen review was conducted, and it was found that the pharmacist made recommendations for Resident #172's drug regimen. The clinical record only revealed that the pharmacy review was done, and the box was checked to See report for Time Sensitive recommendation. On 6/10/24 at approximately 2:00 PM an interview was conducted with the Regional Nurse Consultant who was asked where to find the recommendations that were addressed by the physician, and she stated if they were not in the record, she would have to pull them from the website. On 6/10/24 at 3:10 PM the Clinical Nurse Consultant came back to submit the pharmacy reviews and stated, I will not waste any more of your time, the consults have not been addressed, and I have given them to the Nurse Practitioner to address at this time. Resident #172 was discharged from this facility and the Time Sensitive recommendations were not addressed during his stay. On 6/10/24, during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided prior to the survey's exit.3. For Resident #4, the facility staff failed to respond and act on the Pharmacy Consultant recommendations identified on Monthly Medication Reviews. Resident #4 was admitted to the facility on [DATE] and was a bed bound Resident with multiple medications. The Resident was cognitively impaired and was fully dependant on staff for all activities of daily living such as hygiene, dressing and eating. On 6-6-24 the Resident's clinical record was reviewed. The review revealed that on 4-8-24, Resident #4's medication regimen was reviewed by the Registered Pharmacist (RPH), and the pharmacy consultant (RPH) documented in the clinical record See report for noted irregularities and/or recommendations. The report could not be found. On 6-6-24, The Director of Nursing (DON) and Administrator were asked to supply the report. They responded an hour later and stated they could not locate the report which denoted irregularities. On 6-6-24, an interview was conducted with the Pharmacy (RPH) (Corporate #3). She stated that she and her colleague did perform monthly medication reviews. She went on to describe that those reviews were completed electronically and uploaded to a web site (name given) where the facility would go in and retrieve the reports and recommendations monthly. She stated that only the DON (Director of Nursing) and Administrator had password access credentials to get into the information. She further stated that the Medical Director for this facility did not have access granted and the Administrator or DON would have to print the report and give it to him to act upon. Both the Administrator and DON stated they had not done that, and so none of the reports nor recommendations had been reviewed nor acted upon by the doctor for approximately 3 months or longer. Review of the clinical record revealed no documentation of the Physician's response to the recommendations. On 6-6-24, and 6-7-24 the Administrator and DON were made aware of the non-compliance, and they stated the incident would be rectified immediately. 4. For Resident #25, the facility staff failed to respond and act on the Pharmacy Consultant recommendations identified on Monthly Medication Reviews. Resident #25 was admitted to the facility on [DATE]. The Resident was a recent leg amputee with confusion and psychiatric illness. The Resident was cognitively impaired and was extensively dependant on staff for all activities of daily living such as hygiene, dressing and eating. On 6-6-24 the Resident's clinical record was reviewed. The review revealed that on 4-27-24, Resident #4's medication regimen was reviewed by the Registered Pharmacist (RPH), and the pharmacy consultant (RPH) documented in the clinical record See report for noted irregularities and/or recommendations. The report could not be found. On 6-6-24, The Director of Nursing (DON) and Administrator were asked to supply the report. They responded an hour later and stated they could not locate the report which denoted irregularities. On 6-6-24, an interview was conducted with the Pharmacy (RPH) (Corporate #3). She stated that she and her colleague did perform monthly medication reviews. She went on to describe that those reviews were completed electronically and uploaded to a web site (name given) where the facility would go in and retrieve the reports and recommendations monthly. She stated that only the DON (Director of Nursing) and Administrator had password access credentials to get into the information. She further stated that the Medical Director for this facility did not have access granted and the Administrator or DON would have to print the report and give it to him to act upon. Both the Administrator and DON stated they had not done that, and so none of the reports nor recommendations had been reviewed nor acted upon by the doctor for approximately 3 months or longer. Review of the clinical record revealed no documentation of the Physician's response to the recommendations. On 6-6-24, and 6-7-24 the Administrator and DON were made aware of the non-compliance, and they stated the incident would be rectified immediately.

Based on staff interview and review of facility documents, the facility staff failed to keep identified systems functioning properly, and to implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee; including to identify deficiencies in the area of Qualifications of an Activity Professional as well as repeated deficiencies, and to have the Director of Nursing (DON) and/or a designee participate in the 7/23/24 QAPI meeting. The findings include: On 8/7/24 at 4:10 PM a QA&A (Quality Assessment and Assurance) interview was conducted with the Administrator regarding the QAPI meeting that took place on 7/23/24. The Administrator stated that during the QAPI meeting all of the deficient citations from the Plan of Corrections survey ending 6/13/24 were discussed. The Administrator also stated that all of the audits were discussed related to the Plan of Corrections. During this interview the Administrator stated that the facility currently does not have a qualified professional directing the facility activities program. In the following areas the facility repeated deficient practices; Services Provided Meet Professional Standards, ADL Care Provided for Dependent Residents, Activities Meet Interest/Needs Each Resident, Qualifications of Activity Professional, Pharmacy services, Label/Store Drugs and Biologicals, Frequency of Meals/Snacks at Bedtime, Food Procurement, Store/Prepare/Serve-Sanitary, Use of Outside Resources, and Use of Transfer Agreement. At the conclusion of the QA&A interview with the Administrator on 8/7/24 at 4:10 PM, the Administrator stated that the Director Of Nursing was not present and did not participate in the QAPI meeting on 7/23/24. A review of the QAPI sign in sheet failed to identify the DON or an individual designated to represent the DON participated in this meeting. On 8/8/24 at approximately 7:45 PM, a final interview was conducted with the Administrator, Director of Nursing, and the Regional Nursing Consultant. They had no further comments and voiced no concerns regarding the above information.

Based on staff interviews, and facility documentation, the facility failed to determine training needs based on its facility assessment and maintain a training program for all new and existing staff. The findings included: The facility failed to maintain a training program for all new and existing staff. A review of the staff Training Transcripts, and Staff Education files revealed that none of the 19 staff transcripts reviewed had completed all the mandatory training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the staff development and training program. She stated that the education and training files are up to date. On 6/13/2024, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that all direct care staff completed mandatory Effective Communication training. The findings included: The facility failed to ensure that all direct care staff completed mandatory Effective Communication training. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of mandatory Effective Communication training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resource (HR) Director who was asked about direct care staff having completed mandatory Effective Communication training. She stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before survey exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that all employees are educated on resident rights and responsibilities of the facility. The findings included: The facility failed to ensure that staff members were educated on resident rights and responsibilities of the facility. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of Resident Rights training and the responsibilities of the facility. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about direct care staff having completed mandatory Resident Rights training. She stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that staff members had completed the mandatory Abuse, Neglect, and Exploitation training. The findings included: The facility failed to ensure that staff members had completed the mandatory Abuse, Neglect, and Exploitation training. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of mandatory Abuse, Neglect, and Exploitation training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director. She was asked about staff education regarding Abuse, Neglect, and Exploitation training. She stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on staff interviews, facility documentation review, the facility staff failed to ensure all staff received mandatory infection control training. The findings include: Review of the staff training records indicated the following facility staff did not have mandatory infection control training: The Director of Nursing (DON), CNA #8, Others #9, Others #10, Others #11, Others #12, Others #13, and Others #14. The above findings were shared with the Administrator, Corporate Nurse #1, and Corporate Nurse #2 on 6/13/2024 at approximately 11:45 AM. No further information was provided prior to the conclusion of the survey.

Based on facility staff interviews, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training. A review of the staff's Training Transcripts and Staff Education files revealed that 19 direct care staff had not documented completion of mandatory Ethics and Compliance Training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about staff training regarding, Ethics and Compliance Training. She stated that the training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey exit.

Based on facility staff interviews, and facility documentation, the facility failed to ensure that the nurse aides had a minimum of 12 hours of in-service training including dementia, abuse prevention and facility assessments, and special needs of the residents in a year. The findings included: The facility failed to ensure that nurse aides have a minimum of 12 hours of in-service training within 12 months to meet the needs of the residents. A review of the staff's Training Transcripts and Staff Education files revealed that not all nurse aides completed the mandatory 12 hours of in-service education and training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about nurse aides' in-services and education. She stated that training and education are recorded in their computer-based platform and that the files are correct and up to date. On 6/13/2024, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on facility staff interview, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. A review of the staff Training Transcripts, and the Staff Education files for 19 staff members revealed that six (6) of the staff reviewed had not completed the mandatory Behavioral Health Training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about staff training regarding, the mandatory Behavioral Health Training. She stated that the training and education are recorded in their computer-based platform and that the files are correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey exit.

Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in substandard quality of care. The findings included: During the recertification survey conducted 6/4/24 through 6/7/24 and 6/10/24 through 6/13/24 residents were identified who could benefit from meaningful and individualized activity programs. A further review of the activities program revealed that the previous Director of Recreation separated from the facility on 3/28/2023 and a Certified Nursing Assistant (CNA) with an interest in activities volunteered to provide activities for the residents until a qualified professional was vetted. The CNA first assumed the role of Activity Assistant and was officially promoted to the role of Director of Recreation on 3/11/24, contingent the facility paid for the certification program and all testing associated. An interview was conducted with the unqualified Director of Recreation (DoR) on 6/11/24 at approximately 11:00 AM. The DoR stated she had received some training to the position from a DoR from a sister facility but she had not completed a certification program. The DoR further stated the corporate person responsible for the DoRs sent information for her to register for the certification program but when she presented the information to the Administrator after completing the registration form the Administrator stated to wait and never got back with her regarding the certification program. An interview was also conducted with the Administrator and the Corporate Consultant on 6/11/24 at approximately 11:09 A.M. The Administrator stated she was aware that the Activities Professional/Director of Recreation must be a qualified professional as stated in the regulations. At approximately 11:48 A.M., the Administrator provided a document from the National Certification Council for Activity Professionals which indicated a deposit was made to register the unqualified Director of Recreation for the certification program. The facility's Director of Recreation job description revised on 3/2023 stated the Director of Recreation Prerequisites, Skills and Abilities are Bachelor's Degree and qualification as a therapeutic recreation specialist or activities professional; or, Associate Degree and qualified as a therapeutic recreation specialist or activities professional via (1) two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, (2) certification by the National Council of Activity Professionals or other recognized accrediting body, (3) completion of a state-approved activities training course, or (4) current licensure as an Occupational Therapist or Occupational Therapist Assistant. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator and two Corporate Nurse Consultants. They had no further comments regarding the above findings prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, family interview, and staff interviews the facility staff failed to notify the physician and/or the Practitioner of the delay in administering a medication for 13 doses and an acute change in condition (threatening his roommate, other residents, and staff) for one (1) of three (3) residents (Resident #3), in the survey sample. The findings included: Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. The resident was discharged abruptly from the facility on 6/27/21. Resident #3's diagnoses included traumatic brain injury, hemiplegia, a seizure disorder secondary to an assault in 2009, and difficulty walking. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision-making were intact. In section G (Physical functioning) the resident was coded as independent with bed mobility, transfers, toileting dressing, eating, personal hygiene, bathing, and eating after set-up, and limited assistance of one person with walking. During the interview with FM #1 on 6/28/23 at 7:18 p.m., she stated on 6/27/21 at 11:11 am, Resident #3 called her upset, and the weekend supervisor, Licensed Practical Nurse (LPN) #1 called shortly after the call. FM#1 said Resident #3 was exhibiting aggressiveness by threatening residents and staff and was told she had two options, discharge the resident to her or they would have the police remove him from the facility. FM#1 stated she asked for the name of the person she was speaking to on the phone, and the LPN refused to give her name. Resident #3's mother stated when she arrived at the facility, LPN #1 explained that there was not an on-call doctor to give him any medication to calm down, nor did they think that the on-call doctor should be called to give him an extra dose of his Clonazepam; the only thing that they could offer was to talk to him verbally. FM #1 said the LPN would not call the Director of Nursing (DON) or give her a contact number to call the on-call supervisor to get this information directly or to be able to ask further questions. She said LPN #1 stated the DON would not be available until Monday and she was unable to provide any written documentation to show the proper procedure and protocol to handle this type of situation. FM#1 stated she did not know the name of the person she had spoken to on the phone-which she later found out from the police; it was LPN #1. During the above interview, FM #1 stated because of not being able to share her concerns with anyone, she had to decide on how to best proceed from there, because they were going to discharge him no matter how much she pleaded that it was unsafe. Therefore, she took the advice of his community case manager and called the police to file a formal complaint. FM#1 said when the police arrived, they interviewed her and the community case manager. The police also interviewed the facility staff and once all sides were heard, the final decision was made to take Resident #3 to a local emergency room (ER) to determine if he needed a psychological evaluation. She said, After 24 plus hours in the ER, he had his blood drawn to check his levels (sic), and a negative psychological evaluation, which then resulted in his discharge home on [DATE] at 5:30 p.m. A nurse's note dated 6/27/21 at 11:39 a.m. validated the resident had become aggressive with his roommate and was found standing over him threatening to cause him physical harm. read that the resident became aggressive with his roommate and was found standing over him threatening to cause him physical harm. The nurse's note further read the resident had threatened, cursed, and became aggressive to other residents and staff. The note also read the staff tried calming the resident down by speaking with him and contacting FM #1 to speak with him, and he became aggressive over the phone with the FM. The nurse's note finally read, Advised the (FM #1's name) that she can either come to pick the resident up or we will have to call the police to pick him up. Further review of the nurse's notes did not reveal that a Physician and/or Practitioner was notified when the resident was exhibiting behaviors that he had never exhibited before. A telephone interview was conducted with the primary care physician on 6/30/23 at approximately 2:00 p.m. The physician stated several calls came in on 6/27/21 concerning other residents but there was no call regarding Resident #3. The physician was made aware that Resident #3 was admitted with an order for Clonazepam 1 mg two times each day and it wasn't administered to him from 6/17/21 through 6/23/21. The physician stated it was very likely a resident not tapered off of Clonazepam could exhibit aggressive behaviors. The physician also confirmed a Practitioner saw Resident #3 on 6/17/21, 6/18/21, 6/21/21, 6/22/21, and 6/23/21 but the nursing staff did not request a prescription for the Clonazepam until 6/23/21 with a first dose administered on 6/24/21, causing the resident to miss 13 doses. The physician stated the medication reconciliation was not completed with the hospital discharge as it should have, and that also left the margin for error. An interview was conducted on 6/30/23 at approximately 2:20 p.m., with the Administrator and the Corporate Consultant. Corporate Consultant #1 stated a Physician and/or Practitioner is always on call, and with any change in a resident's condition, the on-call Physician and/or Practitioner should be notified. The Administrator stated, The Administrator and/or Director of Nursing are also always available. On 7/3/23 at approximately 5:01 p.m., during another interview with the Administrator and Corporate Consultant #2. Corporate Consultant #2 stated the medication Clonazepam 1 mg was not available for administration to Resident #3 until 6/24/21 because a prescription was not requested from the Physician and/or Practitioner until 6/23/21. The following information was obtained from the website on 6/30/23. Clonazepam is useful alone or as an adjunct in the treatment of the Lennox-Gastaut syndrome (petit mal variant), akinetic, and myoclonic seizures. In patients with absence seizures (petit mal) who have failed to respond to succinimides, clonazepam may be useful. The following paradoxical reactions have been observed: irritability, aggression, agitation, nervousness, hostility, anxiety, sleep disturbances, nightmares, abnormal dreams, and hallucinations. To reduce the risk of withdrawal reactions, use a gradual taper to discontinue clonazepam or reduce the dosage. (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ebc11109-e7bf-452d-b675-4b3236d54164)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family interviews, and staff interviews the facility staff failed to provide a safe, functional, sanitary, and comfortable homelike environment for residents in 2 of 3 halls on Unit I. The findings Included: 1. The facility staff failed to make repairs to walls, ensure the cleanliness of resident rooms as well as secure exposed wires from the heating and air conditioning unit. During an interview with Resident #2's Family Member (FM) #2 on 6/29/23 at approximately 10:40 a.m., she stated on 5/6/23 when FM #2 was admitted to the facility the wall behind the head on the bed exhibited holes, the bedside cabinet contained items from the previous resident and there was dust, and debris in the room (6-B) on the windowsill. The resident was discharged on 5/19/23. On 6/28/23 a large hole remained above the headboard, the heating/air unit was wrapped in a blue tape and wires were observed protruding from beneath the unit. Dark stains were observed on the floor and the windowsill was coated with a large amount of dust and debris. An interview was conducted with the Maintenance Director on 6/28/23 at approximately 5:35 p.m. The Maintenance Director stated whenever the census is low, he has opportunities to repair and plaster the holes in walls because residents must be moved to other rooms to allow for the repairs. On 6/29/23, the Administrator escorted the surveyor to room [ROOM NUMBER]-B to show that the hole had been repaired, but other issues in the room remained the same. 2. The facility staff failed to repair the heating and air conditioning unit that was leaking water as well as ensure the television was operational. An interview was conducted on 6/28/23 at approximately 1:25 p.m., with Resident #1, a current resident admitted on [DATE] who resided in room [ROOM NUMBER]-B. Resident #1 had not been at the facility long enough to have a completed Minimum Data Set (MDS) assessment. The resident was alert and oriented to person, place, time, and situation. Resident #1 stated the heat/air unit had been leaking for several days and the staff was putting, sheets, towel, and blankets down to soak up the water but the unit had not been repaired. An interview was also conducted by phone with Resident #1 FM#3, wife on 7/3/23 at 1:10 p.m. She stated the heating/air unit was leaking puddles of water and staff were putting 2-3 sheets on the floor. She stated on Saturday night 7/1/23 the resident and FM#3 asked if a work order was put in and the staff stated, Yes. FM#3 also stated the TV goes in and out, therefore the resident was using his electronic tablet for entertainment. FM#3 stated she had communicated multiple times with the administrative staff, and she was currently seeking placement in another community. On 7/3/23 at approximately 5:01 p.m., during a final interview with the Administrator and Corporate Consultant #2, the Administrator stated they had a plan to repair other holes that had been identified by the facility staff. The Administrator also stated the heating/air conditioning unit was repaired on 7/3/23 in room [ROOM NUMBER]-B.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, family interview, and staff interviews the facility staff failed to ensure a safe and orderly discharge from the facility for one (1) of three (3) residents (Resident #3), in the survey sample. The findings included: Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. The resident was discharged abruptly from the facility on 6/27/21. Resident #3's diagnoses included traumatic brain injury, hemiplegia, a seizure disorder secondary to an assault in 2009, and difficulty walking. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision-making were intact. In section G (Physical functioning) the resident was coded as independent with bed mobility, transfers, toileting dressing, eating, personal hygiene, bathing, and eating after set-up, and limited assistance of one person with walking. A review of the electronic record revealed a notice of Medicare non-coverage dated 6/23/21 at 4:29 p.m., which stated the resident's last day of coverage would be 6/25/21 and his discharge date was scheduled for 6/26/21. No documentation was in the resident's record to explain why he remained in the facility after 6/26/21 and all staff with knowledge of the resident's discharge plans were no longer employed by the facility. During the interview with Resident #3's Family Member (FM) #1 on 6/28/23 at 7:18 p.m., she stated on Saturday 6/26/21 at approximately 1:00 p.m., she received a phone call from Resident #3 to inform her that the nurse told him that he was to be discharged home that day instead of Monday (6/28/21). FM#1 stated she spoke with the weekend supervisor, Licensed Practical Nurse (LPN) #1 who stated she did not have the updated changes in the system for the nurses to see, but she had talked to administration and confirmed his discharge date was Monday 06/28/21. FM#1 also stated she confirmed with the weekend supervisor that she did not need to do anything else until the social worker called her on 06/28/21. During the interview with FM#1, she stated on 6/27/21 at 11:11 am, Resident #3 called her upset, and a nurse staff member/Licensed Practical Nurse (LPN) #1 called right after. She said that LPN #1 mentioned Resident #3 was exhibiting aggressiveness by threatening residents and staff, and she had two options, discharge the resident to her or they will have the police remove him from the facility. She stated she asked for the name of the person she was speaking to on the phone, and she refused to give her name. FM#1 stated when she arrived at the facility, the weekend supervisor who was LPN #1 explained that there was not an on-call doctor to give him any medication to calm down, nor did they think that the on-call doctor should be called to give him an extra dose of his Clonazepam; the only thing that they could offer was to talk to him verbally. FM #1 also stated that LPN #1 would not call the Director of Nursing (DON) or give her a contact number to call the on-call Registered Nurse (RN) supervisor to get this information directly or to be able to ask further questions. FM#1 stated that LPN #1 said the DON would not be available until Monday (6/28/21) and she was unable to provide any written documentation to show the proper procedure and protocol to handle the current situation. During the above interview, FM #1 stated because of not being able to share her concerns with anyone, she had to decide on how to best proceed from there because the facility was going to discharge him no matter how much she pleaded that it was unsafe. Therefore, she took the advice of his community case manager and called the police to file a formal complaint. When the police arrived, they interviewed her and the community case manager. The police also interviewed the facility staff and once all sides were heard, the final decision was made to take Resident #3 to a local emergency room (ER) to determine if he needed a psychological evaluation. FM#1 said, After 24 plus hours in the ER, he had his blood drawn to check his levels (sic), and a negative psychological evaluation, which then resulted in his discharge home with me on 06/28/21 at 5:30 p.m. A nurse's note dated 6/27/21 at 11:39 a.m. validated the resident had become aggressive with his roommate and was found standing over him threatening to cause him physical harm. The nurse's note further read the resident had threatened, cursed, and became aggressive to other residents and staff. The note also read the staff tried calming the resident down by speaking with him and contacting FM#1 to speak with him and he became aggressive over the phone with the FM. The nurse's note finally read Advised (FM #1's name) she can either come to pick the resident up or we will have to call the police to pick him up. Another nurse's note documented on 6/28/21 at 2:57 p.m. (late entry) read in part once FM#1 arrived on 6/27/21 she stated she didn't want to take the resident home in his current state because she was dealing with the stress of having to [NAME] her granddaughter the same weekend and instead, she wanted the nurse to call the on-call doctor and have him prescribe something to handle the aggression. The nurse stated she advised FM#1 that she could not call to get psych medications for a resident without first having him evaluated with a psych consult. FM#1 stated again that she did not want to take him home and the facility's nurse advised her that due to the resident threatening bodily harm, they could not allow him to stay in the building. FM#1 stated it felt as if the facility was throwing her son away. The nurse supervisor advised her that was not the case and documented she sincerely apologized if that is how FM#1 interpreted the conversation. It was stated to her it was important to her to keep the residents and staff protected and she could not risk the situation escalating without properly intervening. The nurse's note also stated the police officer convinced FM #1 to have Resident #3 transferred to the ER for evaluation and the hospital telephoned the facility to obtain a report of the resident's status and what medications were prescribed. An interview was conducted on 6/30/23 at approximately 2:20 p.m., with the Administrator and Corporate Consultant#1. Corporate Consultant #1 stated a Physician and/or Practitioner is always on call and with any change in a resident's condition the on-call Physician and/or Practitioner should be notified. The Administrator stated the Administrator and/or Director of Nursing are also always available. On 7/3/23 at approximately 5:01 p.m., the above information was shared with the Administrator and Corporate Consultant #2. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no concerns were voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interviews, and clinical record review, the staff failed to apply professional standards of practice and administer medications as ordered for 2 of 3 residents (Resident #2 and #3), in the survey sample. The findings included: 1. The facility staff failed to administer physician ordered Ativan 0.5 mg twice a day on two days, 5/16/23 and 5/18/23. Resident #2 was originally admitted to the facility 5/6/23 and was discharged from the facility to a local hospital on 5/19/23. Resident #2's diagnoses included pneumonia, an anxiety disorder, malnutrition, renal insufficiency, and congestive heart failure. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/12/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with bed mobility, transfers, locomotion, toileting, dressing, personal hygiene and bathing, limited assistance of one person with walking and independent after set-up with eating. During the interview with Resident #2's Family Member (FM) #2 on 6/29/23 at approximately 10:40 a.m., she stated she had always managed Resident #2's medications and was aware of how the resident presented when she had received her Ativan doses as she did at home. FM#2 stated at home Resident #2 received Ativan 1 mg every morning, Ativan 0.5 mg at bedtime and Ativan 0.5 mg every 12 hours as needed for anxiety or insomnia. FM#2 stated Resident #2 was without the Ativan for two days which resulted in an inability to complete therapy as planned. The hospital's Discharge summary dated [DATE] discharged the resident from the hospital with the following Ativan order; Ativan Oral Tablet 0.5 mg, Give 1 tablet by mouth as needed for anxiety 2x daily. The Nurse Practitioner changed the Ativan order on 5/15/23 at 11:09 a.m., from Ativan 0.5 mg as needed 2 times a day to Ativan 0.5 mg, Give 1 tablet by mouth scheduled every 12 hours for anxiety. A review of the medication administration record (MAR) and the control drug reconciliation record revealed on 5/16/23 and 5/18/23 only one dose of Ativan 0.5 mg was administered with no documentation of the rationale. On 7/3/23 at approximately 5:01 p.m., the above information was shared with the Administrator and Corporate Consultant #2. An opportunity was offered to the facility's staff to present additional information, and Corporate Consultant #2 stated based on the information available, the scheduled doses of the Ativan were not administered as ordered on 5/16/23 and 5/18/23. No additional information was provided, and no further concerns were voiced. 2. For Resident #3, the facility staff failed to administer physician ordered Clonazepam 1 milligram (mg) twice a day which resulted in 13 missed doses. Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. The resident was discharged abruptly from the facility on 6/27/21. Resident #3's diagnoses included traumatic brain injury, hemiplegia, a seizure disorder secondary to an assault in 2009 and difficulty walking. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as independent with bed mobility, transfers, toileting dressing, eating, personal hygiene, bathing, and eating after set-up, and limited assistance of one person with walking. A review of Resident #3's physician order summary revealed an order dated 6/17/2021 for Clonazepam Tablet 1 mg, Give 1 tablet by mouth two times a day for seizures. From 6/17/21 through 6/23/21 nurse's notes read as follows: 6/17/21 6:00 p.m. Clonazepam Tablet 1 mg waiting on pharmacy, 6/18/21 10:10 a.m., Clonazepam, on order, 7:23 p.m. Clonazepam, awaiting delivery from the pharmacy. 6/19/21 8:54 a.m. Med not on the cart, 6/19/21 at 7:04 p.m. Clonazepam, awaiting pharmacy. 6/20/21 8:58 a.m., Medication not available due to pharmacy, 6:22 p.m., Clonazepam Tablet 1 mg, Give 1 tablet by mouth two times a day for seizures. 6/21/21 at 4:29 p.m. Clonazepam Tablet 1 mg, at 6:22 p.m., Clonazepam Tablet 1 mg, awaiting pharmacy delivery. 6/22/21 9:21 a.m. Clonazepam Tablet 1 mg, medication on hand, at 7:40 p.m., Clonazepam Tablet 1 mg, awaiting pharmacy delivery 6/23/21 at 8:08 a.m., Clonazepam Tablet 1 mg, Give 1 tablet, on order, at 7:48 p.m. Clonazepam Tablet 1 mg, awaiting pharmacy A telephone interview was conducted with the primary care physician on 6/30/23 at approximately 2:00 p.m. The physician was made aware that Resident #3 was admitted with an order for Clonazepam 1 mg two times each day and it wasn't administered to him from 6/17/21 through 6/23/21. The physician stated it was very likely a resident not tapered off of Clonzepam could exhibit aggressive behaviors. The physician also confirmed a Practitioner saw Resident #3 on 6/17/21, 6/18/21, 6/21/21, 6/22/21, and 6/23/21 but the nursing staff did not request a prescription for the Clonzepam until 6/23/21 which resulted in the resident with 13 missed doses. The physician stated the medication reconciliation was not completed with the discharge as it should have, and that also left the margin for error. On 6/30/23 at approximately 6:00 p.m., the above information was shared with the Administrator and Corporate Consultant #1. An opportunity was offered to the facility's staff to present additional information and Corporate Consultant #1 stated the medication Clonazepam 1 mg was not available for administration to Resident #3 from 6/17/23 through 6/23/21. It became available on 6/24/21 after a prescription was obtained from the Physician and/or Practitioner on 6/23/21. Medication errors are the number-one error in health care (Centers for Disease Control [CDC], 2013). Safe and accurate medication administration is an important and potentially challenging nursing responsibility. Medication administration requires good decision-making skills and clinical judgment, and the nurse is responsible for ensuring full understanding of medication administration and its implications for patient safety (https://med.libretexts.org/Bookshelves/Nursing/Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutcheon)/06%3A_Non-Parenteral_Medication_Administration/6.03%3A_Safe_Medication_Administration).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and staff interviews the facility staff failed to procure Clonazepam 1 mg to meet the needs of one (1) of three (3) residents (Resident #3), in the survey sample. The findings included: Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. The resident was discharged abruptly from the facility on 6/27/21. Resident #3's diagnoses included traumatic brain injury, hemiplegia, a seizure disorder secondary to an assault in 2009 and difficulty walking. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as independent with bed mobility, transfers, toileting dressing, eating, personal hygiene, bathing, and eating after set-up, and limited assistance of one person with walking. A review of Resident #3's physician order summary revealed an order dated 6/17/21 for Clonazepam Tablet 1 mg, Give 1 tablet by mouth two times a day for seizures. From 6/17/21 through 6/23/21 nurse's notes read as follows; 6/17/21 6:00 p.m. Clonazepam Tablet 1 mg waiting on pharmacy, 6/18/21 10:10 a.m., Clonazepam, on order, 7:23 p.m. Clonazepam, awaiting delivery from the pharmacy. 6/19/21 8:54 a.m. Med not on the cart, 6/19/21 at 7:04 p.m. Clonazepam, awaiting pharmacy. 6/20/21 8:58 a.m., Medication not available due to pharmacy, 6:22 p.m., Clonazepam Tablet 1 mg, Give 1 tablet by mouth two times a day for seizures. 6/21/21 at 4:29 p.m. Clonazepam Tablet 1 mg, at 6:22 p.m., Clonazepam Tablet 1 mg, awaiting pharmacy delivery. 6/22/21 9:21 a.m. Clonazepam Tablet 1 mg, medication on hand, at 7:40 p.m., Clonazepam Tablet 1 mg, awaiting pharmacy delivery 6/23/21 at 8:08 a.m., Clonazepam Tablet 1 mg, Give 1 tablet, on order, at 7:48 p.m. Clonazepam Tablet 1 mg, awaiting pharmacy A nurse's note dated 6/27/21 at 11:39 a.m., read the resident had became aggressive with his roommate and was found standing over him threatening to cause him physical harm. The nurse's note further read the resident had threatened, cursed, and became aggressive to other residents and staff. The note also read the staff tried calming the resident down by speaking with him and contacting Family Member (FM) #1 to speak with him and he became aggressive over the phone with the FM. The nurse's note finally read Advised the (FM #1's name) she can either come to pick the resident up or we will have to call the police to pick him up. A telephone interview was conducted with the primary care physician on 6/30/23 at approximately 2:00 p.m. The physician was made aware that Resident #3 was admitted with an order for Clonazepam 1 mg two times each day and it wasn't administered to him from 6/17/21 through 6/23/21. The physician stated it was very likely a resident not tapered off of Clonazepam could exhibit aggressive behaviors. The physician also confirmed a Practitioner saw Resident #3 on 6/17/21, 6/18/21, 6/21/21, 6/22/21, and 6/23/21 but the nursing staff did not request a prescription for the Clonazepam until 6/23/21. The physician stated the medication reconciliation was not completed with the hospital discharge orders as it should have, and that also left the margin for error. On 6/30/23 at approximately 6:00 p.m., during an interview with the Administrator and Corporate Consultant #1. Corporate Consultant #1 stated the medication Clonazepam 1 mg was not available for administration to Resident #3 from 6/17/23 through 6/23/21. They said the medication became available on 6/24/21 after a prescription was obtained from the Physician and/or Practitioner on 6/23/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, family interview and staff interviews the facility staff failed to ensure there were no significant medication errors which had the potential to result in behavioral problems for 1 of 3 residents (Resident #3), in the survey sample. The findings included: Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. The resident was discharged abruptly from the facility on 6/27/21 for exhibiting aggressive behavior to his roommate, other residents and staff. Resident #3 was admitted to the facility on [DATE] for rehabilitation services after an acute hospital stay for more frequent episodes of seizures. The resident was discharged abruptly from the facility on 6/27/21. Resident #3's diagnoses included traumatic brain injury, hemiplegia, a seizure disorder secondary to an assault in 2009 and difficulty walking. Resident #3's diagnoses included traumatic brain injury, hemiplegia, a seizure disorder secondary to an assault in 2009 and difficulty walking. The 5-day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as independent with bed mobility, transfers, toileting dressing, eating, personal hygiene, bathing, and eating after set-up, and limited assistance of one person with walking. A review of Resident #3's physician order summary revealed an order dated 6/17/21 for Clonazepam Tablet 1mg, Give 1 tablet by mouth two times a day for seizures. From 6/17/21 through 6/23/21 nurse's notes read as follows; 6/17/21 6:00 p.m. Clonazepam Tablet 1mg waiting on pharmacy, 6/18/21 10:10 a.m., Clonazepam, on order, 7:23 p.m. Clonazepam, awaiting delivery from the pharmacy. 6/19/21 8:54 a.m. Med not on the cart, 6/19/21 at 7:04 p.m. Clonazepam, awaiting pharmacy. 6/20/21 8:58 a.m. Medication not available due to pharmacy, 6:22 p.m. Clonazepam, Clonazepam Tablet 1mg, Give 1 tablet by mouth two times a day for seizures. 6/21/21 at 4:29 p.m. Clonazepam Tablet 1mg, at 6:22 p.m., Clonazepam Tablet 1mg, awaiting pharmacy delivery. 6/22/21 9:21 a.m. Clonazepam Tablet 1mg, medication on hand, at 7:40 p.m., Clonazepam Tablet 1mg, awaiting pharmacy delivery 6/23/21 at 8:08 a.m., Clonazepam Tablet 1mg, Give 1 tablet, on order, at 7:48 p.m. Clonazepam Tablet 1mg, awaiting pharmacy During the interview with FM #1 on 6/28/23 at 7:18 p.m., she stated on 6/27/21 at 11:11 am, Resident #3 called her upset and a nurse staff member/ Licensed Pracical Nurse (LPN) #1 called right after. LPN #1 mentioned Resident #3 was exhibiting aggressiveness by threatening resident's and staff, and she had two options, discharge the resident to her or they will have the police remove him from the facility. She stated she asked for the name of the person she was speaking to on the phone, and she refused to give her name. FM #1 stated when she arrived at the facility, the weekend supervisor who was LPN #1, explained that there was not an on-call doctor to give him any medication to calm down, nor did they think that the on-call doctor should be called to give him an extra dose of his Clonazepam; the only thing that they could offer was to talk to him verbally. A nurse's note dated 6/27/21 at 11:39 a.m., validated that the resident had became aggressive with his roommate and was found standing over him threatening to cause him physical harm. The nurse's note further read the resident had threatened, cursed, and became aggressive to other residents and staff. The note also read the staff tried calming the resident down by speaking with him and contacting FM #1 to speak with him and he became aggressive over the phone with his mother. The nurse's note finally read Advised FM#1 that she can either come to pick the resident up or we will have to call the police to pick him up. A telephone interview was conducted with the primary care physician on 6/30/23 at approximately 2:00 p.m. The physician was made aware that Resident #3 was admitted with an order for Clonazepam 1 mg two times each day and it wasn't administered to him from 6/17/21 through 6/23/21. The physician stated it was very likely a resident not tapered off of Clonzepam could exhibit aggressive behaviors. The physician also confirmed a Practitioner saw Resident #3 on 6/17/21, 6/18/21, 6/21/21, 6/22/21, and 6/23/21 but the nursing staff did not request a prescription for the Clonzepam until 6/23/21. The physician stated the medication reconciliation was not completed with the hospital discharge as it should have, and that also left the margin for error. On 6/30/23 at approximately 6:00 p.m., during the interview with the Administrator and Corporate Consultant #1. Corporate Consultant #1 stated the medication Clonazepam 1mg was not available for administration to Resident #3 from 6/17/23 through 6/23/21. It became available on 6/24/21 after a prescription was obtained from the Physician and/or Practitioner on 6/23/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on observations, family interviews, and staff interviews the facility staff failed to maintain an effective pest control program on 1 of 3 halls for Resident #1 (24-B). The findings included: Resident #1 was admitted on [DATE] with a diagnosis of Multiple Sclerosis and for rehabilitation services due to increased weakness and shortness of breath. Resident #1 had not been at the facility long enough to have a completed Minimum Data Set (MDS) assessment. The resident was alert and oriented to person, place, time, and situation. An interview was conducted on 6/28/23 at approximately 1:25 p.m., with Resident #1 who resided in room [ROOM NUMBER]-B. Resident #1 stated he had a personal lunch bag in the window and when he opened it to get a snack out of it, ants were inside the bag therefore he was afraid to open it again. On the windowsill, many small black ants were observed crawling around the lunch bag that was seated on the windowsill. Again on 6/29/23 at approximately 2:10 p.m., small black ants were observed on the windowsill and on the windowpane. On 6/30/23 at approximately 1:45 p.m. small black ants were observed on the windowsill as well as crawling on the lunch bag. An interview was also conducted by phone with Resident #1's FM #3 on 7/3/23 at 1:10 p.m. She stated ants are on the windowsill daily and they got in Resident #1's lunch box. She stated she had made her grievances known to the administrative staff and she is now to the point she is seeking another placement for Resident #1. An interview was conducted with the Maintenance Director on 6/28/23 at approximately 5:35 p.m. The Maintenance Director stated the pest control company comes in weekly and upon request, but they stopped leaving invoices of service for the last few months. He also stated that he personally treats areas within the facility when ants are observed. On 7/3/23 at approximately 5:01 p.m., the above information was shared with the Administrator and Corporate Consultant #2. An opportunity was offered to the facility's staff to present additional information. The Administrator provided documentation that the resident rooms were inspected and ready for admission. The Administrator also stated the pest control company was back in the building to eliminate the ants in room [ROOM NUMBER]-B.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to execute the opportunity to provide an advance directive for Resident #8. The findings include: 3. Resident #8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a past medical history that included Essential Hypertension, Pressure Ulcer of the Sacral Region and Feeding difficulties. The current Minimum Data Set (MDS) a quarterly revision with an Assessment Reference Date (ARD) of [DATE] coded the resident as having long and short-term memory problems. A review of the clinical record on [DATE] at 3:02 PM revealed there was no advance directive in the clinical record. During an interview with the Admissions Director on [DATE] at approximately 3:40 p.m., concerning Resident #8's Advanced Directive she stated, I don't have records on Resident #8, they are stored offsite at Iron Mountain Storage. The Policy Advance Directives Effective [DATE] Reads: Documents of declaration for advance directives that are approved by state law will be placed in the medical record as provided by the patient or legally designated agent/representative. The Procedure: A copy of the Center's policies governing the implementation of self-determination of rights is presented upon admission by the Admissions Office and the Notification/Acknowledgment form verifying all communication regarding advance directives to be placed in the Medical Record at the time of admission. On [DATE] at 3:30 p.m. an Interview was conducted via telephone with the Administrator concerning the above issue with the Advance Directive not being located in the residents chart. She stated, We would usually get the POA (Power of Attorney) involved. (If further information is needed involving the Resident). 5. Facility staff failed to ensure Resident #1 and/or her representative was given the opportunity to formulate an advanced directive. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to debility, cardio-respiratory conditions, anemia, heart failure, high blood pressure, and diabetes. Resident #1's most recent MDS (minimum data assessment) was an annual assessment with an ARD (assessment reference date) of [DATE]. Resident #1 was coded as being intact in cognitive function scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #1's clinical record revealed a DNR (Do not Resuscitate) order dated [DATE] that documented the following: The patient is incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make evaluation of the risks and benefits of alternatives to that decision .While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with authority to direct that life prolonging procedures be withheld or withdrawn. Review of Resident #1's Virginia Advance Medical Directive pages 4 through 4 were blank. On [DATE] at 12:44 p.m., ASM (Administrative Staff Member) #1, the Administrator was made aware of the above concerns. Review of facility policy titled, Advanced Directives, documents in part the following: Documents of declaration for advanced directives that are approved by state law (i.e. living wills, Durable power of Attorney and/or Agents for Healthcare Decisions/Healthcare Power of Attorney, appointments for anatomical gifts/organ donations) will be placed in the medical record as provided by the patient or legally designated agent/representative. 1. A copy of the Center's policies governing the implementation of self- determination of rights is presented upon admission by the Admissions Office and the Notification/Acknowledgement Form verifying all communication regarding advanced directives is to be placed in the Medical Record at the time of admission. 2. If the patient chooses to provide advanced directive documents, these documents must be verified as original documents and will be placed in the medical record. 3. An advanced directive is separate from a DNR order; however, a Living Will or other Advance Directive document may actually specify the withholding of CPR which does necessitate the proper securing of a valid DNR order if a DDNR state form, DNR jewelry, or POST form has not accompanied the patient upon admission. 4. Upon admission a licensed nurse must immediately review the advance medical directive documents provided. If the Living Will specifies or declares the withholding of CPR or specifies that they do not want to be resuscitated, a licensed nurse must immediately notify the attending physician and secure a valid DNR order. A valid DNR order is an original order initiated by the physician, an original Virginia Department of Health Durable Do No (sic) Resuscitate Order Form, legible photocopy of the DDNR, DNR jewelry, or POST form. If a valid DNR order is received, a licensed nurse enter the order in the electronic record. No further information was presented prior to exit. Based on observations, clinical record review, staff and resident interviews, and facility document review, it was determined that the facility staff failed to ensure 4 out of 21 residents (#131, #19, #8 and #1) in the survey sample had an opportunity to formulate and Advance Directive. The findings include: 1. Resident #131 was admitted to the nursing facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute cystitis with hematuria (blood), muscle weakness and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognitive skills for daily decision making. On [DATE] at 1:00 p.m., during an interview with Resident #131, she stated she did not have an Advance Directive and had not been approached by any facility personnel about developing one. She stated she did not have a living will and wanted everything to be done for her if she had a medical emergency. On [DATE] at 2:00 p.m., a request was made of the Admission's Director as to whether the resident had an Advance Directive, or that information was presented to give the resident an opportunity to formulate one. On [DATE] at 3:15 p.m., the Admission's Director presented a document titled (Company name) Policies Governing the Implementation of Self-Determination Rights. The resident's signature was in place along with the admission Director's signature. There was no date as to when the signatures were obtained, thus the document was undated. The document gave an opportunity to have the resident receive information regarding advance directives in order to formulate one or opt out. None of the questions were filled out, all were blank. When asked when she had the resident sign the document, she stated, A few minutes ago. Further, the Admission's Director was not able to share if she explained the content of the document to the resident, nor was she able to explain the document to this surveyor. The Admission's Director stated, No one has instructed me on how to fill out this document or help the resident with the document. We ask the resident or the family about a living will or Advance Directive and many come from the hospital with one. We upload the document in the electronic record, but if they don't have one, there is nothing else I know to do. On [DATE] at 3:30 p.m., Resident #131 stated the Admission's Director told her she needed to sign more admission paperwork for treatment, but nothing else was explained to her about the content of the paperwork. On [DATE] at 12:13 p.m., via phone interview, the Administrator validated what the Admission's Director said regarding residents admitted with either a living will or advanced directives and they are placed in the clinical record. She stated she was not familiar with the process of reviewing a document that addressed Advance Directive options with residents for the opportunity to formulate one, but would check further and return with more information. On [DATE] at 2:09 p.m., via phone interview, the Administrator stated the facility staff (Admission's office or Nursing staff) was not ensuring all residents were presented with information to be able to create an Advance Directive if they desired. The policy and Procedures titled, Nursing Policies and Procedures/Advance Directives dated [DATE] indicated the following: A copy of the Center's policies governing the implementation of self-determination of rights is presented upon admission by the Admissions Office and the Notification/Acknowledgment Form verify all communication regarding advance directives is to be placed in the medical record at the time of admission. 2. Resident #19 was admitted to the nursing facility on [DATE] with a diagnoses of COVID-19. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognitive skills for daily decision making. On [DATE] at 2:00 p.m., a request was made of the Admission's Director as to whether the resident had an Advance Directive, or that information was presented to give the resident an opportunity to formulate one. On [DATE] at 3:15 p.m., the Assistant Admission's Director presented a document titled (Company name) Policies Governing the Implementation of Self-Determination Rights. There was an electronic signature dated [DATE] for both the resident and the Assistant Admission's Director. The document gave an opportunity to have the resident receive information regarding advance directives in order to formulate one or opt out. None of the questions were filled out, all were blank. The Assistant Admission's Director was not able to share if she explained the content of the document to the resident, nor was she able to explain the document to this surveyor. The Admission's Director stated, No one has instructed me on how to fill out this document or help the resident with the document. We ask the resident or the family about a living will or Advance Directive and many come from the hospital with one. We upload the document in the electronic record, but if they don't have one, there is nothing else I know to do. On [DATE] at 3:45 p.m., Resident #19 was shown the electronically signed document and replied, I have never seen that and I don't know what that is, but I am getting better and plan to go home very soon. The admission History and Physical indicated the resident was a full code. On [DATE] at 12:13 p.m., via phone interview, the Administrator validated what the Admission's Director said regarding residents admitted with either a living will or advanced directives and they are placed in the clinical record. She stated she was not familiar with the process of reviewing a document that addressed Advance Directive options with residents for the opportunity to formulate one, but would check further and return with more information. On [DATE] at 2:09 p.m., via phone interview, the Administrator stated the facility staff (Admission's office or Nursing staff) was not ensuring all residents were presented with information to be able to create an Advance Directive if they desired.

**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 ensure a safe Hoyer lift transfer which resulted in a fall for one out of 21 sampled residents; Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to debility, cardio-respiratory conditions, anemia, heart failure, high blood pressure, and diabetes. Resident #1's most recent MDS (minimum data assessment) was an annual assessment with an ARD (assessment reference date) of 11/7/20. Resident #1 was coded as being intact in cognitive function scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #1's clinical record revealed that she had experienced a fall on 12/19/20. The following nursing note was documented: Patient was being Hoyer lifted from bed to WC (wheelchair). When lowering to WC patient was on the edge and unable to get back in the chair. Went to readjust patient with Hoyer and while doing so, she slipped out of the vest in very slow motion to the floor. This was a monitored slide/fall by a CNA (Certified Nursing Assistant) and myself. Assessed patient head to toe and all seemed WNL (within normal limits) with the exception of her BP: 180/80 and continued to monitor that. The last BP was 170/78. She says her back is achy in which case @ (at) Tylenol were given to patient to help with the pain. Review of a fall incident report dated 12/19/20 documented the following: Pt (patient) was being Hoyer lifted to her chair. Was sitting on edge of the wheelchair and when attempting to reposition patient into chair she slipped out of vest in slow motion onto the floor .assessed patient from head to toe with no wounds, bleeding, or injuries noted .Got the assistance from the charge nurse and other CNAs to reposition patient into another Hoyer lift and put her right back into bed . Review of Resident #1's care plan dated 10/20/17 and canceled on 2/11/21 documented the following: The resident has an ADL self-care performance deficit r/t (related to) Activity Intolerance. Hands remain swollen. Is unable to move w/c (wheelchair) with hands and feet .Interventions: Assist of 2 staff for transfers and mechanical lift. On 2/18/21 at 2:17 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, the nurse present during the fall. When asked what had happened at the time of the fall on 12/19/20, LPN #1 stated that the CNA (Certified Nursing Assistant) was using the sit to stand lift and was lowering the resident to the wheelchair but that she did not put the resident far back enough in the wheelchair. LPN #1 stated that the CNA unhooked the straps before repositioning the resident, and the resident slid out of the wheelchair as soon as the straps were unhooked. When asked if she had witnessed the fall, LPN #1 stated that the CNA was using the Hoyer lift by herself and that she was called in when the resident was sitting on the edge of the wheelchair. When asked if staff should be utilizing the Hoyer lift or sit to stand lift with just one staff member, LPN #1 stated that they were supposed to use two staff with the sit to stand, especially with the resident being on the heavier side. LPN #1 stated that she had not seen the nursing aide in a while and was not sure if she still worked at the facility. On 2/18/21 at approximately 12:30 p.m., an interview with the CNA who transferred Resident #1 was attempted for an interview. She could not be reached prior to exit. On 2/18/21 at 12:44 p.m., ASM (Administrative Staff Member) #1, the Administrator was made aware of the above concerns. Facility policy titled, Mechanical Lift documents in part, the following: Two nursing staff must assist with mechanical lift and transfer .position chair and lock brakes .move patient over chair and lower into chair. Base of lifter around chair. Detach hooks from seat/sling . No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined that facility staff failed to obtain a physician's order for the use of oxygen for one of 21 residents in the survey sample; Resident #279. The findings included: Resident #279 was admitted to facility on 2/10/21 with diagnoses that included but were not limited to COVID-19, sepsis, and acute respiratory failure. Resident #279's most recent MDS (minimum data set) assessment was an entry assessment with an ARD (assessment reference date) of 2/10/21. Resident #279 did not have a completed MDS assessment. On 2/17/21 at 12:18 p.m., an observation was made of Resident #279. She was sitting up in her wheelchair wearing a nasal cannula that was hooked up to an oxygen (02) concentrator. The 02 concentrator was turned on and at 2 liters of oxygen. On 2/18/21 at 11:15 a.m., a second observation was conducted of Resident #279. She was lying in bed with her nasal cannula in place. When asked how many liters she was receiving, Resident #279 stated that she has always been on 2 liters of oxygen. Review of Resident #279's current POS (Physician Order Summary) failed to evidence an order for oxygen. Review of Resident #279's care plan dated 2/15/21 documented the following: The resident has oxygen therapy r/t (related to) CHF (Congestive Heart Failure) .The resident will have no s/sx (signs/symptoms) of poor oxygen absorption through next review date .Oxygen Settings: 02 via nasal cannula as ordered. On 2/19/21 at 10:47 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, Resident #279's assigned nurse. When asked if there should be an order for the use of oxygen, LPN #1 stated that she would expect an order. When asked why there should be an order for the use of oxygen, LPN #1 stated that she expected an order so that all nursing staff were aware to check on her 02 levels and for any episodes of shortness of breath. When asked if oxygen was also considered a medication, LPN #1 stated that it was. When asked if Resident #279 had an order for the use of her oxygen, LPN #1 stated that she would have to look into that. On 2/19/21 at 12:31 p.m., ASM (Administrative Staff Member) #1, the Administrator sent this writer via email, evidence that a nurse had recently put an order in place for the use of Resident #279's oxygen. The order documented in part, the following: 2/19/21 at 10:52 (a.m.) May use oxygen at 2 liters as needed for comfort. Monitor 02 sats (saturation) once a shift. Keep 02 sats above 92 % (percent). Every shift. On 2/18/21 at 12:44 p.m., ASM (Administrative Staff Member) #1, the Administrator was made aware of the above concerns. Facility policy titled, Respiratory Care documents in part, the following: Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per physician's order and in accordance with standards of practice.

Based on facility document review and staff interviews the facility staff failed to ensure the services of a registered nurse for at least 8 consecutive hours on Saturday 1/30/21 and Sunday 1/31/21. The findings included: The facility's as worked schedules from January 18, 2021 through February 17, 2021 were reviewed for RN (registered nurse) coverage for at least 8 consecutive hours a day, 7 days a week. On Saturday 1/30/21 and Sunday 1/31/21 there was no RN coverage identified on the facility's as worked schedules. On 2/18/21 at 1:30 P.M. a phone interview was conducted with the facility's Scheduler. The Scheduler was asked about RN coverage for Saturday 1/30/21 and Sunday 1/31/21. The Scheduler stated, I don't see where there was an RN for that weekend. The Director of Nursing is the RN coverage during the week. On 2/18/21 at 2:30 P.M. a phone interview was conducted with the facility's Administrator regarding RN coverage on Saturday 1/30/21 and Sunday 1/31/21. The Administrator stated, There was no RN coverage for that weekend. The Unit Manager was out with COVID, our Staff Development Coordinator quit without notice and my Director of Nursing had already worked the previous weekend. We had an agency nurse scheduled but she backed out at the last minute. The Administrator also stated that there was no facility policy for RN coverage. On 2/19/21 at approximately 4:50 P.M. a pre-exit debriefing was held with the Administrator where the above information was shared. Prior to exit no further information was provided.

Based on staff interviews and facility documentation, the facility staff failed to give 2 out of 5 residents in the survey sample (Resident #4 and Resident #12) the opportunity to receive the pneumococcal vaccination. The findings included: 1. Resident #4 was admitted to the nursing facility on 09/30/20. Diagnosis for Resident #4 included but not limited to Hypertension and Cerebral Infarction. The most recent Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 01/04/21 coded Resident #4 with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #4 under section O Special Treatments and Programs (O0300) section (A) asked if the residents Pneumococcal vaccination was up to date; was coded No. In addition, the MDS under section (B) asked if Pneumococcal vaccine not received, state reason; was coded Not offered. Review of Resident #4's immunization record did not display the pneumococcal vaccine was either offered or declined. A phone interview was conducted with the Director of Nursing/Infection Preventionist (DON/IP) and Cooperate on 02/18/21 at approximately 1:15 p.m. When asked if Resident #4 was offered the pneumococcal vaccine, they replied, No, nothing is documented. The DON/IP said the pneumococcal vaccination should have been offered on admission. The DON/IP stated, If the resident refused the vaccination, the refusal should have document. When asked, What is the purpose of the pneumococcal vaccination the DON replied, To stop the resident from getting sick; it helps to prevent pneumonia. 2. Resident #12 was admitted to the nursing facility on 12/30/19. Diagnosis for Resident #12 included but not limited to Chronic Obstructive Pulmonary Disease (COPD.) The most recent Minimum Data Set (MDS) an annual assessment with an Assessment Reference Date (ARD) of 12/19/20 coded Resident #12 with a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #4 under section O under Special Treatments and Programs (O0300) section (A) asked if the residents Pneumococcal vaccination was up to date; was coded No. In addition, the MDS under section (B) asked if Pneumococcal vaccine not received, state reason; was coded Not offered. Review of Resident #12's immunization record did not display the pneumococcal vaccine was either offered or declined. A phone interview was conducted with the Director of Nursing/Infection Preventionist (DON/IP) and Cooperate on 02/18/21 at approximately 1:15 p.m. When asked if Resident #4 was offered the pneumococcal vaccine, they replied, No, nothing is documented. The DON/IP said the pneumococcal vaccination should have been offered on admission. The DON/IP stated, If the resident refused the vaccination, the refusal should have document. When asked, What is the purpose of the pneumococcal vaccination the DON replied, To stop the resident from getting sick; it helps to prevent pneumonia. The above information was shared with Administrator during a debriefing on 2/19/21 at approximately 2:56 p.m. No additional information was provided. The facility's policy titled Admitting (Physician Orders) effective date: 03/24/20. -Policy: admission Physician Orders must be provided for every patient at the time of admission or readmission to activate a medical plan of care. Procedure - read in part: 1. Upon every patient's admission or readmission or re-entry to the Center, a license nurse will notify the physician requesting and/or verifying physician's orders. 2. Upon receiving admission physician's orders from the physician, the nurse will record the order to include: B. admission orders read in part: Pneumococcal vaccine unless contraindicated.

Based on information obtained during the Resident Council Meeting, observations and interviews, the facility staff failed to display advocacy agencies addresses, and telephone numbers in a manner the residents could utilize. The findings included: A resident council meeting was held in the resident dining hall on 10/03/2018 from 10:00 AM to 10:35 AM. Six residents attended the meeting. The residents were not aware of how to obtain or utilize the Long-Term Care Ombudsman's contact information or other advocacy agencies. They were also unaware of the role of the Long-Term Care Ombudsman. On 10/03/18 at approximately 3:20 PM an interview was conducted with the Activity Director regarding the residents in the Resident Council Meeting stating that they were not aware of who the Ombudsman was and the role of the Ombudsman. The Activity Directory stated that she would educated the residents to the facility posting and on the role of the Ombudsman. The Activity Director stated that the advocacy agencies addresses and phone numbers were displayed on the wall in the hallway. The advocacy posting was in a glass picture frame not at eye level if a resident was sitting in a wheel chair. The print on the display appeared small. The Activity Director was asked if she could get a resident to read the advocacy sign. She said that she would find a good reader to read the posting. The sub headings were typed in bold upper case print. The print had an approximate font size of 16 with the remainder of the wording with an approximate font size of 12: Resident Rights, How To Resolve A concern, How To File A Grievance, How To Contact the following agencies for issues: OLC (Office of Licensure and Certification, LTC Ombudsman, APS.(Adult Protective Services). The first wheel chair bound resident was asked to read the posting in the facility hallway, but stated that the print was too small to read. The posting was lowered on the wall by facility staff. The activity director stated that she could find another resident to read the sign again. On 10/03/18 at approximately 5:00 PM Resident was asked to read the sign once it was lowered on the wall but he stated that the print was too small to read. The Activity Director informed the surveyor at approximately 5 PM that she had started informing most residents where the Resident rights, ombudsman's info were posted including the contact lists as well as where to locate the survey book. No postings were found in the resident rooms. The facility's policy titled Prevention/Screening Training dated 06/20/16 states that the Administrator grievance forms are available for the individual and or family to complete. Investigation and resolution of grievances shall be completed the prevention of abuse and neglect and misappropriation of property by performing background checks on all employees and by advocating and enforcing patient rights and providing patients, families, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution. The procedure states that a poster with the current names, addresses, and telephone numbers of all pertinent state client advocacy groups (such as the state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit) is posted in the Center in an area that is readily accessible to patients and their families. The above findings were shared with the Administrator and Director of Nursing on 10/04/2018 at approximately 7:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #38 was re-admitted to the facility on [DATE]. Diagnosis for Resident #38 included but not limited to Chronic Respiratory Failure. The current Minimum Data Set (MDS), a 14-day assessment with an Assessment Reference Date (ARD) of 9/18/18 coded the resident with a 8 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The Discharge MDS assessments was dated for 08/08/18-discharge return anticipated and re-admitted to the facility on [DATE]. On 08/08/18, according to the facility's documentation, Resident #38 was found with labored breathing, lung sounds wet and coarse. Resident #38 had vomited thick brown emesis. Resident's vital signs were; BP (176/102), P (119), R (26), T (97.6), 02 saturations at 74% on 4/Liters. The facility called 911, Resident #38 was transferred to local ER and admitted with a diagnosis of Aspiration Pneumonia. An interview was conducted with the admission Coordinator and admission Director on 10/04/18 at approximately 3:30 p.m. The both stated, Since they were given the bed hold policy upon admission, they did not know they had to give them a copy of the bed hold policy when they were discharged out to the hospital. The facility administration was informed of the finding during a briefing on 10/04/18 at approximately 5:10 p.m. The facility did not present any further information about the findings. The facility's policy titled Bed Reserve (Revision date: 02/05/15). -Policy: The Admissions Director will ensure the proper documentation is executed for any patient desiring to voluntarily reserve a bed. -Procedure: -The admissions Director must establish contact with the patient and/or responsible agent to determine bed retention arrangements once the patient's hospitalization has been confirmed. -The admission Director will inform the patient/responsible representative of the payment amount necessary for the requested accommodation of days. -The Admissions Director will establish a time for signing of the Voluntary Bed Retention Agreement and the collection of payment. Based on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy for 3 of 23 resident's (Resident #2, #30 and #38) in the survey sample. 1. The facility staff failed to provide the resident (Resident #2) and/or resident's representative with a written copy of the bed hold policy upon transfer to the hospital. 2. The facility staff failed to provide the resident (Resident #30) and/or resident's representative with a written copy of the bed hold policy upon transfer to the hospital. 3. The facility staff failed to provide the resident (Resident #38) and/or resident's representative with a written copy of the bed hold policy upon transfer to the hospital. The findings included: 1. Resident #2 was originally admitted to the facility 9/18/18, was discharged return anticipated from the facility to an acute care hospital 9/23/18 due to an acute illness. The resident returned to the facility 9/25/18. The current diagnoses included; a subarachnoid hemorrhage (a brain bleed) with right side weakness. No Minimum Data Set (MDS) assessments had not been completed which included a Brief Interview for Mental Status (BIMS) score. The Director of Nursing (DON) stated the resident was usually alert and oriented to person, place and time. The 9/18/18, discharge MDS assessment revealed in section G (Physical functioning) the resident was coded as requiring supervision of 1 person with eating, limited assistance of 1 person with locomotion, extensive assistance of 1 people with dressing, and toileting, extensive assistance of 2 people with bed mobility and transfers and total care of 1 person with bathing. Review of the clinical record revealed a nurse's note dated 9/23/18, which stated Resident #2 complained of numbness and tingling of the right leg and an inability to stop the spasms in the left leg. The note stated the resident insisted on a transfer to the local hospital. An interview was conducted with Resident #2 on 10/3/18, at approximately 12:20 p.m. The resident stated she didn't remember the facility staff giving her written information the day she was discharged from the facility to the hospital related to reserving her bed while hospitalized . The hospital's discharge summary revealed the resident was admitted [DATE] and discharged [DATE]. On 10/04/18 at approximately at 3:20 p.m., an interview was conducted with the admission Director and the admission Coordinator. They both stated they were unaware it was a requirement to offer resident's discharged to the hospital a bed-hold for they provided bed-hold information upon admission to the facility. On 10/4/18, at approximately 6:15 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided. 2. Resident #30 was originally admitted to the facility 8/17/18, was discharged return anticipated from the facility to an acute care hospital 9/17/18 due to an acute illness. The resident returned to the facility 9/23/18. The current diagnoses included; heart failure. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/24/18 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. In section G (Physical functioning) the resident was coded as requiring supervision of 1 person with eating, limited assistance of 1 person with in room walking and personal hygiene, extensive assistance of 1 person with bed mobility, transfers, locomotion, dressing, toileting, and bathing. Review of the clinical record revealed a nurse's note dated 9/17/18, which stated Resident #30 was sent to a local acute care hospital per the responsible party's request; for chest pain. The 9/23/18, hospital discharge summary stated the resident was admitted for exacerbation of heart failure. An interview was conducted with Resident #30 on 10/3/18, at approximately 12:30 p.m. The resident stated the facility staff didn't give her or her daughter written information the day she was discharged from the facility to the hospital related to reserving her bed while hospitalized . On 10/04/18 at approximately at 3:20 p.m., an interview was conducted with the admission Director and the admission Coordinator. They both stated they were unaware it was a requirement to offer resident's discharged to the hospital a bed-hold for they provided bed-hold information upon admission to the facility. On 10/4/18, at approximately 6:15 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided.

**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 #17) in the survey sample who were unable to carry out activities of daily living (ADL) receives the necessary services to maintain fingernail care. The facility staff failed to ensure that fingernail care was provided to Resident #17. The findings included: Resident #17 was re-admitted to the facility on [DATE]. Diagnosis for Resident #17 included but not limited to *Cerebrovascular Accident (CVA-stroke) with left *hemiplegia. *CVA is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die (https://medlineplus.gov/stroke.html). *Hemiplegia is the loss of muscle function on one side of the body (https://medlineplus.gov/druginfo/meds/a682514.html). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 08/20/18 coded Resident #17 with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #17 requiring extensive assistance of two with personal hygiene. Resident #17's comprehensive care plan with a revision date of 03/08/17 under ADL self-care performance deficit related to stroke with dense left hemiplegia did not include the care or maintenance of fingernail care/hand hygiene. On 10/02/18 at approximately 10:24 a.m., during the initial tour resident #17 voiced concerns that his fingernails needed to be cut and cleaned. Resident #17's fingernails were observed to be long, thick with a dark brown substance under them. On the same day at approximately 1:05 p.m., the resident's fingernails remained unchanged. On 10/03/18 at approximately 10:20 a.m., the Director of Nursing (DON) assessed Resident #17's fingernail with the surveyor present. The DON stated, Yes, his fingernails need to be cut, cleaned and trimmed. The DON said all resident's fingernails and toenails should be looked at twice weekly on shower days by the Certified Nursing Assistant (CNA) and they are to inform the nurses when nail care is needed. An interview was conducted with CNA #1 on 10/03/18 at 4:05 p.m.who was assigned to give Resident #17 his shower on 10/02/18 (3-11 shift). The CNA stated, I saw that Resident #17 needed his fingernails cut last night but I did not have enough time. She (CNA) stated, Time ran out; I would have cut them tonight but he was not my resident. On 10/03/18 at approximately 5:40 p.m., Resident #17 was observed with his fingernails cut, trimmed and clean. Resident stated, Thank you. The facility administration was informed of the finding during a briefing on 10/4/18 at approximately 5:10 p.m. The facility did not present any further information about the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review and facility documentation, the facility staff failed to follow physician orders for 1 of 23 (Resident #27) in the survey. The facility staff failed to follow physician orders for a wound care dressing change to Resident #27's right elbow with a diagnosis of *Methicillin Resistant Staphylococcus Aureus (MRSA) infection. *MRSA is an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections (https://www.mayoclinic.org/diseases-conditions/mrsa/symptoms-causes/syc). The findings included: Resident #27 was admitted to the facility on [DATE]. Diagnosis for Resident #27 included but not limited to Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Resident #27 Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 09/11/18 coded Resident #27's Brief Interview for Mental Status (BIMS) scored of 05 out of a possible score of 15 indicating severe cognitive impairment. In addition, the MDS coded Resident #27 total dependence of one with bathing, extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene, extensive assistance of one with dressing and supervision with eating for Activities of Daily Living care. The MDS with an ARD of 09/11/18 under section M (Skin Condition - M0100) was coded: Under section (M1040) for other ulcers, wounds and skin problems was coded for surgical wounds and skin tear and under section (M1200) for skin and treatments was coded for surgical wound care and applications of ointments/medications (other than feet). Also, the MDS for active diagnosis under Infections was coded for Multidrug-Resistant Organism (MDRO - MRSA). The comprehensive care plan dated 09/24/14 with a revision date of 09/25/18 identified Resident #27 with actual impairment to skin integrity to right elbow surgical wound. The goal set for the resident by the staff was that the resident would have no complications related to surgical wound of the right elbow. Some of the interventions/approaches the staff would use to accomplish this goal included to keep skin clean and dry, use lotion on dry skin and change *mepilex (foam dressing) to right elbow as ordered. On 10/03/18 at approximately 1:00 p.m., a wound care observation was conducted with License Practical Nurse (LPN) #3. Resident #27 was lying in bed, positioned on her left side. Prior to starting wound care to Resident #27, LPN #3 washed her hands x 24 seconds the donned a pair of gloves. The LPN removed the dressing from the surgical wound to Resident #27's right elbow; the dressing was dated 10/02/18; (3-11 shift). The surveyor asked LPN #1, What is the date and shift written on the dressing being removed from the right elbow, she replied, 10/2/18 (3-11 shift). Review of the Resident #27's clinical record evidenced a physician order dated 01/18/18 revealed the following: clean right elbow with *Dermal Wound Cleanser (DWC), cover with gauze and mepilex every shift. This order was also noted on the Treatment Administration Record (TAR) for October 2018. The review of Resident #27's October 2018 TAR, the nurse had signed off on 10/02/18 (11p-7a shift) that the dressing change was completed to the surgical wound to resident's right elbow. A call was placed to LPN #3's cell phone on 10/4/18 at approximately 10:15 a.m. LPN #3 was the nurse assigned to change the surgical wound dressing to Resident #27's right elbow on 10/2/18 (11-7 shift). A message was left to call the surveyor. The LPN returned the call but was missed. Another call was placed to LPN #3 on the same day at 11:05 a.m., with no return call. An interview conducted with Director of Nursing (DON) on 10/04/18 at approximately 2:00 p.m., who stated, I expect for the nurses to follow the physician orders. Resident #27's dressing change should have been completed as ordered. The facility administration was informed of the finding during a briefing on 10/04/18 at approximately 5:10 p.m. The facility did not present any further information about the findings. The facility's policy titled General Wound Care Dressing Changes (Revision date: 02/01/15). Policy: A license nurse will provide wound care/dressing changes as ordered by physician.

Based on review of the resident's medical chart, staff interview, and review of the facility's policy the facility staff failed to assure each resident's medication regimen was reviewed monthly for 1 of 23 residents (Resident #3), in the survey sample. The facility staff failed to review Resident #3's medication regimen during the month of April 2018. The findings included: Resident #3 was originally admitted to the facility 2/26/14 and has never been discharged from the facility. The current diagnoses included; an anxiety disorder, depression and arthritis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3 cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring set-up assistance of 1 person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. Resident #3 Physician's order summary for 10/1/18 revealed the resident was currently receiving 16 prescribed medications. Clinical record notes revealed, pharmacy review progress notes dated 10/16/17, 11/14/17, 12/9/17, 1/16/18, 2/8/18, 3/9/18, 5/10/18, 6/15/18, 7/23/18, 8/24/18 and 9/28/18. There was no review for April 2018. An interview was conducted with on 10/14/18, with the the Director of Nursing (DON). The DON stated, it is the facility's expectation for each resident's medication regimen to be reviewed by the pharmacist monthly. On 10/4/18, at approximately 6:15 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided. The facility's policy titled Medication Regimen Review, with a revision dated of 12/1/17, read at #10. If an irregularity does require urgent action but should be addressed before the consultant pharmacist's next monthly Medication Regimen Review.

Based on observation, staff interviews and facility documentation review the facility staff failed to ensure one medication cart was stored in a secured location, accessible to designated staff only. The facility staff failed to ensure medication cart containing medication in the hallway was locked when not in direct site of the nurse. The findings included: On 10/03/18 at approximately 6:20 p.m., the medication cart on the back hall was observed to be unlocked when not in direct view of the nurse. The surveyor waited at the medication cart for approximately 4 minutes before the License Practical Nurse (LPN) #4 returned to her med cart. The surveyor asked, Should your medication cart be locked when not in direct view of the nurse she replied, Yes, I should have checked to make sure my cart was locked before I walked away. On the same day at approximately 6:30 p.m., an interview was conducted with Unit Manager (UM) who stated, The nurse should have made sure her medication cart was locked before she walked away. The facility administration was informed of the finding during a briefing on 10/04/18 at approximately 5:10 p.m. The Director of Nursing (DON) stated, The nurse should have doubled checked to make sure her medication cart was locked before she left. The facility did not present any further information about the findings. The facility's policy: Medications - 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles (Last revision Date: 10/31/16). Applicability: This Policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. General Storage Procedures: -3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety. The food service staff failed to ensure foods stored in refrigerated units were labeled and dated appropriately when open; and failed to store employee lunch in an area designated for staff use only. The findings included: On 10/02/18 at 7:55 a.m., during the initial inspection of the kitchen with the dietary cook, the following was observed: 1. Inside the walk in refrigerator was a container of raw chicken; not labeled and dated. 2. Inside the walk in freezer was a bag of mixed vegetables, bag of cinnamon rolls and bag of pulled chicken, all items were open; not labeled and dated. 3. Inside the reach in refrigerator were pre-made salads for the residents along with an employee lunch box. On 10/02/18 at approximately 8:00 a.m., the surveyor asked the dietary cook, Should the raw chicken, mixed vegetables, cinnamon rolls and bag of pulled chicken be labeled and dated he replied, Yes the dietary cook immediately labeled and dated the chicken but discarded the mixed vegetables, cinnamon rolls and pulled chicken from the walk in freezer. An interview was conducted with the Food Service Director on 10/02/18 at approximately 8:40 a.m., who stated, Yes, all foods should be labeled and dated once opened. An interview was conducted with the Dietary Manager on 10/02/18 at approximately 9:05 a.m., who stated, All food items should be labeled and dated after they have been opened and employees should not put their personal lunch in the resident's refrigerator in the main kitchen. The facility's policy titled Refrigerated and Frozen Foods (Effective date: 09/14/18). -Policy: Foods stored in the refrigerator or freezer will be stored in a manner which maintains the food so that it is safe to eat, and retains optimal nutrient content and aesthetic quality. -Procedure: All refrigerated and frozen containers will be labeled, indicating the name of the product and use-by-date. The facility's policy titled Outside Food/Microwave Use (Effective date: 09/14/18). -Procedure: Employee foods should only be stored in areas specifically designated for employees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility documentation review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 23 residents (Resident #27) in the survey sample. The facility staff failed to ensure Resident #27's Treatment Administration Record (TAR) was accurate for the right elbow surgical wound dressing change. The findings included: Resident #27 was admitted to the facility on [DATE]. Diagnosis for Resident #27 included but not limited to Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Resident #27's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 09/11/18 coded Resident #27's Brief Interview for Mental Status (BIMS) scored of 05 out of a possible score of 15 indicating severe cognitive impairment. In addition, the MDS coded Resident #27 total dependence of one with bathing, extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene, extensive assistance of one with dressing and supervision with eating for Activities of Daily Living care. The MDS with an ARD of 09/11/18 under section M (Skin Condition - M0100) was coded: Under section (M1040) for other ulcers, wounds and skin problems was coded for surgical wounds and skin tear and under section (M1200) for skin and treatments was coded for surgical wound care and applications of ointments/medications (other than feet). Also, the MDS for active diagnosis under Infections was coded for Multidrug-Resistant Organism (MDRO - MRSA). On 10/03/18 at approximately 1:00 p.m., a wound care observation was conducted with License Practical Nurse (LPN) #3. Resident #27 was lying in bed, positioned on her left side. Prior to starting wound care to the Resident #27, LPN #3 washed her hands x 24 seconds the donned a pair of gloves. The LPN removed the dressing from the surgical wound to Resident #27's right elbow; the dressing was dated 10/02/18; (3-11 shift). The surveyor asked LPN #1, What is the date and shift written on the dressing being removed from the right elbow, she replied, 10/02/18 (3-11 shift). Review of the Resident #27's clinical record evidenced a physician order dated 01/18/18 revealed the following: clean right elbow with *Dermal Wound Cleanser (DWC), cover with gauze and *mepilex (foam dressing) every shift. This order was also noted on the Treatment Administration Record (TAR) for October 2018. The review of Resident #27's October 2018 TAR, the nurse had signed off on 10/02/18 (11p-7a shift) that the dressing change was completed to the surgical wound to resident's right elbow. A call was placed to LPN #3's cell phone on 10/4/18 at approximately 10:15 a.m. LPN #3 was the nurse assigned to change the surgical wound dressing to Resident #27's right elbow on 10/02/18 (11-7 shift). A message was left to call the surveyor. The LPN returned the call but was missed. Another call was placed to LPN #3 on the same day at 11:05 a.m., with no return call. An interview conducted with Director of Nursing (DON) on 10/04/18 at approximately 2:00 p.m. The surveyor asked the DON, When do you expect for the nurses to document a resident's treatment has been completed on the TAR she stated, I expect for the nurses to sign off on the TAR only after the treatment has been completed. The facility administration was informed of the finding during a briefing on 10/04/18 at approximately 5:10 p.m. The facility did not present any further information about the findings. The facility's policy titled Nursing Documentation (Revision: 02/01/15). Procedure in part: 3. Entries will be made as soon as possible after an event or observation is made. An entry will never be made in advance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #27 was admitted to the facility on [DATE]. Diagnosis for Resident #27 included but not limited to Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Resident #27 Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 09/11/18 coded Resident #27's Brief Interview for Mental Status (BIMS) scored of 05 out of a possible score of 15 indicating severe cognitive impairment. In addition, the MDS coded Resident #27 total dependence of one with bathing, extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene, extensive assistance of one with dressing and supervision with eating for Activities of Daily Living care. The MDS with an ARD of 09/11/18 under section M (Skin Condition - M0100) was coded: Under section (M1040) for other ulcers, wounds and skin problems was coded for surgical wounds and skin tear and under section (M1200) for skin and treatments was coded for surgical wound care and applications of ointments/medications (other than feet). Also, the MDS for active diagnosis under Infections was coded for Multidrug-Resistant Organism (MDRO - MRSA). The care plan dated 05/21/15 with a revision date of 02/21/18 identified Resident #27 comprehensive care plan with history of chronic MRSA in right elbow surgical wound and takes *Bactrim DS daily prophylactically. The goal set for the resident by the staff was that the resident will be free from complications related to infection through the next review. Some of the interventions/approaches the staff would use to accomplish this goal included to administer medication as ordered, monitor/document/report signs and symptoms of infections to physician and maintain precautions (contact) as ordered. *Bactrim DS are both antibiotics that treat different types of infections caused by bacteria (drugs.com). Review of the Resident #27's clinical record evidenced a physician order dated 02/01/18 revealed the following: Bactrim DS tablet 800-160 mg-give 1 tablet by mouth one time a day for MRSA. This order was also noted on the Medication Administration Record (MAR) for October 2018. On 10/03/18 at approximately 1:00 p.m., a wound care observation was conducted with License Practical Nurse (LPN) #3. Prior to starting wound care to Resident #27, LPN #1 washed her hands x 24 seconds then donned a pair of gloves. The LPN placed a barrier pad covering Resident #27's personal over bed table without disinfecting the table. The LPN did not remove the TV remote or water pitcher from the over bed table. The LPN placed all treatment supplies on the barrier which consisted of the following: *Mepilex dressing, 4x4 gauzes and wound cleanser . The LPN placed a small red biohazard bag at the foot of residents bed. The LPN removed her gloves, washed her hands x 21 seconds then donned another pair of gloves. She then removed the dressings from the surgical wounds to the right elbow; two open areas were observed. The soiled dressing removed were placed in biohazard bag. A large amount of serosanquious drainage was noted on the dressing removed but without odor. The proximal wound was cleansed with wound cleaner x 2 in a circular motion, gloves removed, hands washed x 16 seconds, gloves donned then wound bed covered with mepilex dressing. The distal wound was cleansed with wound cleaner x 2 in a circular motion, gloves removed, hands washed x 23 seconds, gloves donned then wound covered with mepilex dressing. The LPN removed all wound care supplies from the over bed table then placed the over bed table at resident's bedside without disinfecting it. An interview was conducted with LPN #1 on 10/03/18 at approximately 2:55 p.m., who stated, I should have disinfected the over bed table before and after treatment and also I should have removed the TV remote and the resident's water pitcher before starting wound care. An interview was conducted with Staff Development Coordinator on 10/04/18 at approximately 11:59 a.m., who stated, All personal items should have been removed prior to starting wound care treatment. The table should have been wiped down with antibacterial wipes; let the table dry completely, cover the over bed table with a barrier, place items on the barrier, complete treatment, remove barrier, wipe table again with antibacterial wipes let the table dry completely then replace personal belongings. The facility administration was informed of the finding during a briefing on 10/04/18 at approximately 5:10 p.m. The facility did not present any further information about the findings. 1. The facility's policy titled Infection Prevention and Control Policies and Procedures Handwashing Requirements was dated 12/26/17. The policy read at procedure A1t; after any contact with potentially contaminated materials (used wound/treatment/dressings), procedure D3; change gloves during patient care when moving from a contaminated body site to a clean body site. 2. The facility's Treatment Observation Non-Sterile Treatment Technique (Last revision: 1/18). Observations to read in part: Clean and sanitize surface before placing waterproof barrier on table. Based on observations and staff interviews the facility staff failed to maintain effective infection control practices during the provision of care for 2 of 23 residents (Residents #39 and 27), in the survey sample. 1. The facility staff failed to perform hand hygiene during wound care for Resident #39. 2. The facility staff failed to disinfect Resident #27's personal over bed table before after being used to perform a wound care dressing change that was being treated for *Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The findings included: 1. Resident #39 was originally admitted to the facility 7/25/18 and has never been discharged from the facility. The current diagnoses included; a stage 4 pressure ulcer of the sacrum and an unstageable pressure ulcer of the left heel. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #X cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring set-up with eating, supervision of 2 or more with personal hygiene, extensive assistance of 1 person with dressing, extensive assistance of 2 people with bed mobility, and total care of 1 with toileting and bathing. In section M (Skin Condition) the resident was coded as having an 1 unstageable pressure and 1 stage 4 pressure ulcer present and a potential for additional skin problems. A physician order dated 9/25/18, read change wound vacuum Monday, Wednesday and Friday every evening shift. Wound vacuum suction at 125 every shift. Another physician order dated 10/3/18, read cleanse left heel with betadine, cover with gauze and Allevyn every evening shift until healed. The current care plan problem revised 9/25/18 read; skin impairment, sacral ulcer stage 4, left heel necrotic deep tissue injury. Has a wound vacuum. The goal read; the resident will have no evidence of skin impairment through next review 10.30/18. the interventions included; moisture barrier cream as needed for protection of skin, pressure reduction mattress, weekly skin assessments. Wound care as ordered was not an intervention. On 10/3/18 at approximately 2:10 p.m., pressure ulcer care for Resident #39 was observed. Licensed Practical Nurse (LPN) #8 was observed removing the old wound vacuum drainage canister, dressing and tubing. LPN #8 didn't remove the gloves or perform hand hygiene after removal of the soiled dressing. LPN #8 then cleaned the resident's sacral pressure ulcer with 4 by 4 gauze and wound cleanser, afterwards she removed the gloves and again didn't perform hand hygiene with sanitizer or soap and water. LPN #8 attached the new wound vacuum tubing to the new canister, allowing the tubing ends to make contact with the bed linens. LPN #8, cut the foam dressing and placed it on the bed. The biocclusive dressing was prepared, the foam dressing was placed on the pressure ulcer, another sponge dressing was applied and a hole was made in the foam sponge for the canister tubing, the scissors were placed on the bed, the biocclusive dressings was and the tubing was applied. The pump was turned on and the dressings was held to allowed the wound vacuum to seal. LPN #8 changed the gloves, again she did not sanitized or wash her hands. New gloves were applied, a protective barrier was applied around the wound vacuum dressing, and a piece of tape with the date on it was applied the the dressing. LPN #8 put an incontinence brief was on the resident and positioned him in bed. LPN #8 again, removed the gloves, washed her hands and new gloves were donned. The dressing to the left heel was removed. No hand hygiene was performed prior to cleaning the left heel pressure ulcer. The left heel was cleaned with wound cleanser and 4 by 4 gauze, betadine was painted on the left heel, followed by 4 by 4 gauze, a dressing and a non-skid sock was applied. The wound care supplies were removed from the table, the table was cleaned and the trash was discarded. An interview was conducted on 10/3/18, at approximately 6:00 p.m., with the Director of Nursing. The Director of Nursing stated hand hygiene should take place when going from soiled to clean, and after removing gloves and anytime indicated during wound care. On 10/4/18, at approximately 6:15 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided.