Based on observation, resident interview, staff interview and facility document review, the facility staff failed to ensure a clean, comfortable and homelike environment in two resident rooms on a portion of B wing, specifically known as the B-Back hall. Findings include: On 11/01/22 at approximately 11:15 AM, Resident #34 was interviewed in his room, which had a bedside commode (used by Resident #34) sitting at the end of the bed. The bedside commode had a dry, smeared brown substance on the inside and around the sides of the bucket. The toilet seat also had a dry, brown substance that was smeared on it. When asked if staff clean the bedside commode, Resident #34 replied, Yes. Additional observations in the room included the following: The built in closet had paint chipped off with large scratches on the front and sides; the cabinet had some scraped, indented areas in the wood along the edges and sides; the resident's sink had a large brownish stain around the drain about 2-3 inches in diameter; the pipe under the sink had a flange ring detached from the wall and hanging on the pipe; and the top cabinet of the closet had an entire door missing. No hinges or even hardware were present. When asked how long the closet had been without a door, Resident #34 said that it had been like that for quite a while. When asked what happened to the door to the closet, Resident #34 stated, It got gone. On 11/01/22 at approximately 11:40 AM, Resident #335's was interviewed in her room, along with her daughter, who was present. Resident #335's daughter stated that the resident's sink was dirty and she had asked someone to clean it, but it had not been done yet. The sink had some soiled areas that were dry. The resident's floor around the heating unit (attached to the wall) was soiled and had debris build up around the edges of the wall at the bottom of the heating unit and around the power outlet. The power outlet had dirt buildup and rust around the casing of the outlet. Resident # 335's daughter stated that it had been like that since the resident arrived on 10/12/22. Both resident rooms were observed in the same condition as described above multiple times each day during the survey process from November 1, 2022 through November 3, 2022. On November 3, 2022 at approximately 7:30 AM, the resident rooms were again observed in the same manner as described above, except the sink in Resident #335's room had been wiped and/or cleaned. On 11/03/22 at 7:45 AM, LPN (Licensed Practical Nurse) #6 was interviewed and asked who is responsible to clean bed side commodes. The LPN stated that it is the CNA's responsibility and that if it is the actual bathroom that housekeeping takes care of that. On 11/03/22 at approximately 7:50 AM, CNA (certified nursing assistant) #4 was then interviewed and asked if she was working with Resident #34 today. The CNA stated that she was not, but had worked on that hall, with that resident/room the day before. The CNA was asked to go to the room with the soiled bedside commode. The CNA stated that they (CNA's) are supposed to clean them after each use. The CNA stated that the resident didn't use the bedside commode yesterday, he only used the urinal and stated that she didn't notice the day before that the bedside commode was soiled/dirty and therefore, didn't clean it. On 11/03/22 at 8:03 AM, The Maintenance Supervisor (MS) was asked how does the maintenance department go about checking on resident rooms that may need repairs. The MS stated that it is a daily thing and that they (he and the assistant) will go and check on things. The MS stated that they are constantly painting and replacing things. The MS stated that they make their rounds daily and the nurse's should be reporting things too. The MS observed Resident #34's room that included the resident's stained sink, the pipe under the sink and the door missing from resident's closet. The MS stated, Yea, that didn't just get like that. The MS did not provide any explanation and/or knowledge of why those items observed had not been fixed and/or addressed. On 11/03/22 at approximately 8:50 AM, the MS was again asked how are maintenance issues/concerns logged and tracked for repair or replacement. The MS stated that he and his assistant make rounds every day, all day and are constantly looking for items in need of repair. The MS also stated that the nurse's have a log book at the nurse's station where they can write in items of concern for the maintenance department to check, repair or replace. The MS then stated that, a lot of times the facility staff will tell him in passing of concerns or things that need to be fixed and he will write it down, if he remembers and has time, or may try to fix at that time if possible, but stated that if he is busy sometimes those things could be missed. The MS looked in the log book for the B-wing and stated that he did not see anything in the book related to the issues pointed out regarding the two resident rooms above. The MS was asked for a policy or procedure on how repairs are to be identified, logged and tracked for completion and what the expectation was for general resident room maintenance. The MS stated that he didn't really have anything in writing. On 11/03/22 at approximately 9:30 AM, the administrator was made aware of the above information and asked for a policy/protocol on the maintenance expectations for resident rooms. The administrator presented a policy titled, .Preventative Maintenance Program .shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public .maintain a schedule of maintenance services .shall assess all aspects of the physical plant to determine if preventative maintenance is required .may be determined by maintenance request, grand rounds, life safety requirements, or experience .decide what tasks need to be completed and how often to complete them .develop a calendar to assist with keeping track of all tasks .documentation shall be completed for all tasks .Tels is the software .used to document and schedule preventative maintenance . On 11/03/22 at approximately 10:30 AM, the administrator, DON (director of nursing), ADON (assistant director of nursing) and corporate nurse were made aware in a meeting with the survey team of the above findings. No further information and/or documentation was presented prior to the exit conference on 11/03/22 to evidence a clean, comfortable and homelike environment was maintained for the above residents and their rooms.

Based on complaint investigation, clinical record review, and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS - a cms assessment tool) for one of 21 residents (Resident # 82) in the survey sample. Resident # 82, who was discharged to home, was incorrectly identified as being discharged to an acute care hospital on a Nursing Home Discharge Minimum Data Set. The findings include: Resident # 82 was admitted to the facility with diagnoses that included a left wrist fracture, cancer, hypertension, generalized muscle weakness, difficulty walking, right below the knee amputation, dysuria, bromhidrosis, frequency of micturition, and urinary urgency. According to a Nursing Home Discharge Minimum Data Set with an Assessment Reference Date of 8/19/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section A (Identification Information), at Item A2100, Discharge Status, Resident # 82 was identified as being discharged to an acute hospital. Review of the Progress Notes in Resident # 82's closed electronic health record revealed the following entry: 8/19/2022 - 11:45 a.m. - Discharge Note - Resident discharged from facility to home. All personal items packed by resident. Resident walked out of facility on own At approximately 9:30 a.m. on 11/2/2022, the Social Worker, who also serves as the Discharge Planner, was interviewed. According to the Social Worker, the discharge of Resident # 82 was a planned discharge. Asked how the MDS Coordinator is made aware of discharges, the Social Worker explained that a Utilization Meeting is held daily that includes a discussion of discharges. The MDS Coordinator is present at that meeting, the Social Worker said. The MDS Coordinator was unable to be interviewed due to an extended illness. During a meeting at 4:00 p.m. on 11/2/2022, that included the Administrator, Director of Nursing, Assistant Director of Nursing, Corporate Nurse Consultant, and the survey team, the inaccuracy of Resident # 82's discharge assessment was discussed. No additional documentation was provided prior to exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #62's care plan was not reviewed and revised to include the physician orders for TED (thrombo- embolic deterrent/therapeutic support) hose to be applied daily for edema. Resident #62 was admitted to the facility with hypertension, artherosclerotic heart disease, sick sinus syndrome, presence of cardiac pacemaker, diabetes mellitus, cognitive impairment, and a history of falls. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/07/2022, assessed Resident #62 with a BIMS (Brief Interview for Mental Status) score of 5/15, indicating moderate cognitive impairment for daily decision making. Resident #62's clinical record was reviewed on 11/01/2022 at approximately 2:30 p.m. Review of the physician orders included the following orders, which were both written on 09/19/2022: Apply TED hose daily to BLE (bilateral lower extremities). Nursing staff to assist her with this task, one time a day for edema. Remove TED hose @ HS (hour of sleep) Nursing staff to assist with this task, one time a day for edema. On 11/02/2022 at approximately 9:30 a.m., Resident #62 was observed in her room, dressed for the day. No TED hose were observed. When asked if she had white stockings that staff helped her put on in the mornings and took off in the evening, Resident #62 stated, No, I don't have that. When asked if she had any stockings in her drawers, Resident #62 opened her drawers and stated, No, I don't have any. CNA (certified nursing assistant) #1 was in the hallway and confirmed that she was assigned to Resident #62. When asked about the physician ordered TED hose, CNA #1 stated, .I don't know if she is supposed to be wearing TED hose or not. When asked if she had reviewed Resident #62's [NAME] (daily care guide) prior to caring for her, CNA #1 stated, I haven't looked at it recently .the nurses tell us what we are supposed to do . The CCP and the [NAME] were reviewed at approximately 10:15 a.m., the TED hose were not observed on either. At approximately 11:30 a.m., RN #1 came to the conference room. She was asked how CNAs knew to apply TED hose if they were not on a resident's [NAME]. She stated, It was on the nurse's MAR (medication administration record) .the nurse tells the CNA to assist the resident, but it should be on the care plan and the [NAME]. The above information was discussed with the administrator, the DON (director of nursing), the ADON (assistant director of nursing) and three corporate staff during an end of the day meeting on 11/02/2022 at approximately 5:30 p.m. No further information was obtained prior to the exit conference on 11/03/2022 that indicated that facility staff had addressed the individualized need for the physician ordered therapeutic hose in Resident #62's comprehensive care plan. Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of twenty residents in the survey sample (Resident #17 & #62). Resident #17's Comprehensive Care Plan (CCP) was not revised regarding the provision of colostomy care. Resident #62's plan of care was not updated to include the physician ordered intervention of therapeutic support hose (TED hose). The findings include: 1. The Comprehensive Care Plan for Resident #17 was not revised to address the provision of colostomy care by the resident. Resident #17 was admitted to the facility with diagnoses that included inflammatory bowel disease with colostomy, asthma, history of cerebral infarction, diverticulosis, atrial fibrillation, hypothyroidism, depression, anxiety, hypertension and chronic respiratory failure. The minimum data set (MDS - cms asssessment tool) dated 9/9/22 assessed Resident #17 as cognitively intact for daily decision making. On 11/1/22 at 12:06 p.m., Resident #17 was interviewed about quality of care in the facility. Resident #17 stated during this interview that she provided her own colostomy care that included twice weekly flange changes. Resident #17 stated the aides assisted her to clean around the colostomy site during showers. When asked further about the specifics of her colostomy care, Resident #17 stated that she emptied the colostomy bag daily, changed the bag/flange, made sure the skin around the site was clean, and notified the nurses of any problems. Resident #17's CCP (revised 7/6/22) documented that the resident had a colostomy but made no mention that the resident provided her own care. Interventions to maintain function of the colostomy and prevent skin breakdown included, Assess daily to make sure ostomy is functioning properly .Change Ostomy bag per MD [physician] orders and prn [as needed] if bag is leaking or bursts .Notify Charge nurse if no stool is passed each shift .skin will be inspected at ostomy site, around stoma for s/s [signs/symptoms] of irritation .respect [Resident #17's] dignity when providing ostomy care . There were no revisions to the colostomy care part of the CCP since 9/24/20, but there was no documentation that the identified care interventions were being followed. Also, no problems, goals and/or interventions were listed regarding the resident #17's self-care of the colostomy. On 11/2/22 at 2:37 p.m., the licensed practical nurse (LPN #2) caring for Resident #17 was interviewed. LPN #2 stated the resident performed her own colostomy care. LPN #2 stated Resident #17 was specific about how the care was done and used supplies provided by the facility. When questioned about the self-care not being included in the care plan, LPN #2 stated that the unit manager took care of updating care plans. On 11/2/22 at 3:10 p.m., the unit manager (LPN #3) was interviewed about Resident #17. LPN #3 stated she was responsible for care plan updates/revisions. LPN #3 stated Resident #17 routinely performed her own colostomy care. LPN #3 reviewed the current plan of care and stated there was nothing on the plan about the resident performing colostomy self-care. LPN #3 stated, It definitely should have been on there that she does her own care. These findings were reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 11/2/22 at 5:40 p.m. No further information was obtained prior to the exit conference on 11/03/2022 that indicated that the Comprehensive Care Plan had been developed and implemented to address the self-care of Resident #17's colostomy.

Based on observation and staff interview the facility staff failed to ensure a safe room environment for one of 21 residents, Resident #62. Findings were: Resident #62 was admitted to the facility with hypertension, artherosclerotic heart disease, sick sinus syndrome, presence of cardiac pacemaker, diabetes mellitus, cognitive impairment, and a history of falls. A quarterly MDS (minimum data set - cms assedsment tool) with an ARD (assessment reference date) of 10/07/2022, assessed Resident #62 with a BIMS (Brief Interview for Mental Status) score of 5/15, indicating moderate cognitive impairment for daily decision making. Initial tour of the facility was conducted on 11/01/2022 at approximately 12:00 noon. Resident #62 was observed standing in the doorway of her room. An area of purple/blue discoloration was observed around her right eye. When asked what had happened to her eye, Resident #62 stated, I fall. When asked how she fell, Resident #62 stated, My mattress is slicky. Resident #62 then invited this surveyor into her room and stated, See my mattress? I was getting up and slid off the blankets. When asked if she had called for help prior to the fall, Resident #62 stated, When I falled I yelled, Help! Help! Review of the clinical record on 11/01/2022 at approximately 2:30 p.m., provided documentation that Resident #62 had recently fallen while getting up unassisted with the resulting fall and subsequent injury indicated by the discoloration around her eye. A review of the comprehensive care plan revealed new fall interventions that included the addition of a night light in her room. On 11/02/2022 at approximately 9:00 a.m., a Caution Wet Floor sign was observed in the doorway to Resident #62's room. The floor in Resident #62's room had been recently mopped and was very visibly wet (indicating increased fall risk/hazard). Resident #62 was observed walking in her room between the bed and wall. The wetness of the floor and the need for caution was pointed out to Resident #62, who stated, I'm being careful, I've got my shoes on. The housekeeper (other staff #1) who had mopped the floor was around the corner, on another hallway. When asked if she had mopped Resident #62's floor, other staff #1 stated, Yes .I asked [name of Resident #62] to sit on the bed until it dried. Other staff #1 was then told that the resident was not sitting on her bed, that she was up walking in her room, and the floor was visibly very wet. When asked if there was a dry mop or something that could be run over the floor to get up the excess water, Other Staff #1 took a dry mop to the room and ran it over the floor to expedite the drying process. Review of the care plan included the following information: high risk of falls r/t (related to) incontinence .[Name of Resident #62] needs a safe environment with even floors free from spills and/or clutter . The above findings was discussed with the administrator, the DON (director of nursing), the ADON (assistant director of nursing), and three corporate staff during an end of the day meeting on 11/02/2022 at approximately 5:30 p.m. Concerns were voiced that the floor had been left visibly wet in a resident's room, especially a resident with a known fall history and interventions to reduce fall risk. The administrator stated, I overheard you talking to her [OS #1] this morning. I went to the housekeeping director and he met with his staff. No further information was obtained prior to the exit conference on 11/03/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to notify the physician of a delay in the treatment of a UTI (urinary tract infection) for Resident #28. Findings were: Resident #28 was admitted to the facility with the following diagnoses including but not limited to: Diabetes mellitus, quadriplegia, contracture of the left hand, UTI, and chronic kidney disease. An annual MDS (minimum data set - a cms assessment tool), dated 09/02/2022, documented the BIMS (Brief Interview for Mental Status) score of 15 (out of 15), indicating intact cognitive function for daily decision making. The clinical record was reviewed on 11/01/2022 beginning at approximately 3:00 p.m, noting the progress notes with the following entries: 10/29/2022 22:20 (10:22 p.m.) Positive for UTI. Spoke with (Name); place PICC line begin ertapenem 1 GM (gram) q (every) 24 hours. 10/31/2022 (Note from nurse practitioner signed 10/31/2022 at 7:51 p.m.) .Infection and inflammatory reaction due to indwelling urethral catheter .urine culture came back with E. Coli and Pseudomonas. She is on trimethoprim 50 mg daily for UTI prophylaxis, however, she has developed a UTI again. She should continue ertapenem 1 g daily until 11/4/2022. Foley care should be performed every shift and the catheter should be changed every 28 days . 11/01/2022 01:27 (a.m.) Ertapenem Sodium Reconstituted 1 GM Use 1 gram intravenously one time a day for UTI over 4 days. IV therapy to begin tomorrow 11-1 @1700 per MD order, noted change in (computer system) as well. Written by the unit manager, RN (registered nurse) #1, a change in condition note was observed in the clinical record at approximately 9:10 a.m. on 11/02/2022. It contained the following: 11/02/2022 08:56 (a.m.) Change in Condition .nursing observations, evaluation, and recommendations are: Resident presents with UTI, Foley catheter in place. Treatment with Ertapenem 1 Gm IV X (times) 4 days . On 11/02/2022 at approximately 9:30 a.m., RN #1 was interviewed. In reference to the 11/02/2022 change in condition note, written earlier that day, RN #1 was asked if she was aware that the antibiotics for Resident #28 had not yet been started. She looked at the physician orders and stated, Yes, it starts this evening. She was referred back to the progress notes from 10/29/2022, 10/31/2022, and 11/01/2022 regarding Resident #28's orders for an IV antibiotic. At approximately 11:30 a.m., RN #1 came to the conference room and stated, The antibiotic order was written by the on-call physician over weekend. It looks like the original order was written on October 29 to place a PICC line and discontinue it when the antibiotics were complete. That order was discontinued. There was also an order written on October 29 for the antibiotics to be given for four days .that was discontinued and rewritten to start on November first .that order was discontinued on November 1st, the reason on the order was waiting on IV supplies from the pharmacy and they were suppose to be here today .I don't know what happened .some of the notes say we were waiting on the medicine, some say waiting on IV supplies. It looks like we ordered the medicine from the pharmacy .we have that antibiotic here so it could have been started .I spoke with the nurse practitioner and we got the order clarified so we can give it IM starting today at noon. She was asked if the physician or nurse practitioner had been notified that the medication had not been given before today. She stated, There isn't any documentation that notification occurred, I don't feel like that happened. She was asked if the nurses had changed/canceled the orders and the start dates of the antibiotic without speaking with the physician or the nurse practitioner. She stated, Yes, that is what I think happened .the physician should have been notified. On 11/02/2022 at approximately 3:30 p.m., the nurse practitioner was interviewed. She was asked if she was aware that Resident #28 had not received any doses of her antibiotics prior to the IM injection earlier on 11/02/2022. She stated, I was told on Monday (10/31/2022) that she had an IV and that it had infiltrated .I can't tell you the nurses name who told me that, but she said there weren't any needles here to restart it and they would have to come from the pharmacy .I thought she had gotten one dose and it would resume the next day (11/01/2022). I found out today that none had been given, we changed the route to IM so it could start as soon as possible. On 11/02/2022 at approximately 4:00 p.m., RN #1 was asked if other than the clinical record there was any place the nurses could have documented that the antibiotic was not given and the physician/nurse practitioner were notified. She stated, There is a physician book. She went to the nurse's station and looked in the book. She stated, There's not any documentation in here about that. The above information was discussed with the DON, the administrator, the ADON (assistant director of nursing) and three members of the corporate staff. Concerns were voiced that an IV antibiotic had been ordered on 10/29/2022 for four doses and the medication was not started until 11/02/2022. The DON was asked if the physician or Nurse practitioner had been notified of the delay in treatment. She stated she would see what she could find out. On 11/03/2022 at 9:30 a.m., the DON came to the conference room. She was asked if she could clarify if the physician had been notified of the delay in treatment for Resident #28. She stated, I've not been able to get in touch with the nurses .I don't know if the physician was notified or not, or if the problem was they didn't know we had the meds or if they thought the IV supplies weren't available .either way the physician should have been notified I don't see any record of that. The facility policy Unavailable Medications contained the following information: Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: .Notify physician of inability to obtain medication upon notification or awareness that medication is not available .If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification . No further information was obtained prior to the exit conference on 11/03/2022. Based on resident interview, staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to notify the physician and/or RP (responsible party) of a change in condition for three of 21 residents in the survey sample (Resident #34, Resident #78 and Resident #28). 1. The facility staff failed to notify Resident #34's RP of a wound. 2. The facility staff failed to notify Resident #78's physician of the resident being in pain and/or that the resident's pain medication was not available for administration. 3. The facility staff failed to notify the physician of a delay in the treatment of a UTI (urinary tract infection) for Resident #28. Findings include: 1. Resident #34's diagnoses included, but were not limited to: HTN (high blood pressure), CHF (congestive heart failure), schizophrenia, asthma, Parkinson's disease, anxiety disorder, polyneuropathy, obesity, and depression. The most current MDS (minimum data set) was a quarterly review (this MDS was prior to the discovery of the resident's wound). This MDS assessed the resident with a cognitive score of 12, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive to full assistance with ADL's (activities of daily living) with assistance of two staff. The resident's most recent full MDS assessment with CAAS (care area assessment summary) (prior to the wound discovery) was an annual assessment dated [DATE]. The MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. The resident triggered in the CAAS section of this MDS for pressure ulcers. A complaint investigation was completed on 11/01/22 through 11/03/22. An allegation within the complaint alleged that the RP/family of Resident #34 was not notified of the discovery of the resident's wound on 07/29/22. The resident's clinical records were reviewed. According to the resident's clinical records, the resident was found with bilateral 'friction' wounds to the dorsal area of both feet on 07/29/22 per the resident's weekly skin assessment (dated 07/29/22). The resident's records were further reviewed and did not evidence that the resident's RP/family had been notified of the above information. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), and corporate nurse were made aware of the above complaint allegation in a meeting with the survey team. The DON and staff were made aware that no information was found regarding notification of this incident to the resident's RP/family in the resident's records and was asked for assistance in locating any information. The DON stated that it was true, the facility staff did not notify the resident's RP/family of the resident's wounds and/or the progression of the resident's wounds that were discovered on 07/29/22. The DON stated that they had recognized notification as problem. According to the facility policy on wound care, the policy states, .notification to physician and/or responsible party regarding wound or treatment changes . No further information and/or documentation was presented prior to the exit conference on 11/03/22 at 11:30 AM to evidence that Resident #34's RP/family was notified of a change in condition regarding the resident's skin. This is a complaint deficiency. 2. Resident #78's diagnoses included, but were not limited: diverticulitis, atrial fibrillation, depression, muscle weakness, dysphagia, abnormal gait, polyneuropathy, history of falls, and musculoskeletal mastoid bone pain. The resident's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident was assessed as requiring supervision with limited assistance of one staff person for ADL's (activities of daily living). On 11/02/22 at approximately 7:55 AM, Resident #78 was interviewed in her room. The resident was sitting on the side of the bed. The resident stated that she had a rough night, was in pain and had not slept due to the pain. The resident stated that she had asked the night nurse for her ordered pain medication (hydrocodone) and stated that the nurse told her that they (the facility) didn't have any. The resident stated the nurse told her they didn't have it. The resident was asked what her pain was at the present moment and the resident stated that her pain was a 7 on a scale of 1-10 (one being minimal pain and 10 being the worst pain). The resident stated that they were supposed to change the medication order from a pill form to liquid form and that the nurse told her that it was still on order and had not arrived from the pharmacy. The resident stated that she was hurting and stated that she hoped she wouldn't start crying from it. At approximately 8:05 AM, LPN (Licensed Practical Nurse) #1 (the resident's day nurse) was made aware of Resident #78's complaints of pain and not getting any pain medication the night before, as the night shift nurse had told her the medication was not available. LPN #1 looked in the system and confirmed that the resident had an order for: .[order date: 10/31/22 10:32 am] Hydrocodone-Acetaminophen solution 2.5 -108 mg/5 ml (milligrams/milliliter) Give 5 ml by mouth at bedtime for mastoid bone pain Start Date: 10/31/22 . The LPN looked further and stated that the resident did not get the medication the night before (11/01/22 at 10 PM) and and that it looked like the medication was on order according to the nursing/EMAR (electronic medication administration record) note written by the night nurse. The LPN stated that it shouldn't take that long for a medication to get here and stated, it was ordered on 10/31/22. The LPN was asked to look on the medication cart to see if the medication was there. The LPN began looking for the ordered medication and found the bottle of medication. The LPN looked at the bottle and stated, this is it. The bottle had the resident's name and the date dispensed as 10/31/22. The LPN stated, that doesn't make sense and went on to say that the she didn't understand why the medication was not given if the medication was here. The LPN was asked to look at the narcotic sheet for this medication to see if any had been signed out. The LPN pulled the narcotic sheet for this medication. The sheet documented the date the medication was received as 10/31/22. No doses were signed off as administered. The LPN was then asked to look to see if the resident had received pain medication at bedtime on 10/31/22. The LPN looked and stated that the resident had not received pain medication on that night either. At approximately 9:30 AM, Resident #78's clinical records were reviewed. The resident's MAR (medication administration records) for October and November 2022 were reviewed. On 10/31/22 and 11/01/22 at 10:00 PM, the resident's MAR documented a '9' in the the slot for the above pain medication. The MAR legend for '9' means 'other/see nursing notes'. The resident's nursing notes were reviewed. On 10/31/22 the nursing note documented, 10/31/2022 5:00 PM .Orders - General Note .you have entered HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain . On 11/1/2022 an EMAR note documented, .1:35 AM - Medication Administration Note .HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain Pending pharmacy delivery @ this time. New mediation RX . On 11/2/2022 an EMAR note documented, .12:17 AM - Medication Administration Note . HYDROcodone-Acetaminophen Solution 2.5-108 MG/5ML Give 5 ml by mouth at bedtime for mastoid bone pain Medication pending delivery @ this time. Res resting in bed w/ eyes closed . There were no notes found to evidence that the resident's physician was notified that the pain medication was not given or that the pain medication was not available. On 11/02/22 at 3:10 PM, the NP (Nurse Practitioner) was made aware of the above information regarding Resident #78's interview about being in pain last night and not being able to sleep and stating that she had a rough night. The NP stated that the resident has mastoid bone arthritis and that this information was verified by the resident's daughter. The NP stated that they have tried several things to include, gabapentin -which didn't really help according to the NP. The NP stated that she did increase it that and that the resident is now on a low dose of Norco (the medication that was not administered on 10/31/22 and 11/01/22). The NP stated that other medications were tried, but stated that the Norco 2.5 mg seemed to do better for this resident. The NP was asked what would the expectation be for a situation like Resident #78's, if the resident doesn't have pain medication or the medication is not available to administer. The NP stated that with someone like her (Resident #78) she would have told the nurse to give the resident a one time dose of an alternate medication that was actually on hand. The NP stated that she was not on call and that she was not made aware. The NP stated, I do feel bad, I do think something is going on with her regarding this pain. The NP stated that the resident does have an upcoming appointment. The NP stated that when any resident is in pain and their pain medication is not available or they don't have pain medication ordered her (the NP) expectation would be for the nurse to call the provider. The NP stated that for this resident the nurse could have contacted the provider and obtained an order to give an alternative pain medication of something preferably in house and stated that staff could have crushed a pill (after contacting the provider) and put it in applesauce to give, whatever they needed to do, in order to prevent a delay in treating the resident's pain. The NP again stated the nurse should have contacted the provider. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing) and the corporate nurse were made aware that the resident's pain medication was on the medication cart and was found this morning by LPN #1 and that according to the label on the medication bottle and the narcotic sheet the medication was delivered on 10/31/22 and no medication doses had been administered from it. The facility staff were made aware that according to the above information and the resident's clinical records (MARs/TARs) the resident had not received the medication for two nights and the resident's provider had not been contacted either night. On 11/02/22 at 6:35 PM, the DON stated that the expectation would be and is for the nurse to notify the provider to get an order for something pain. No other information and/or documentation was provided prior to the exit conference on 11/03/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to develop a comprehensive care plan (CCP) for 4 of 21 residents in the survey sample (Resident #23, #78, #80, and #81). Resident #23 had no plan of care for anticoagulant (AC) medication and diabetic management, including insulin administration. Resident #78 had no plan of care developed/implemented for pain management. Resident #80 had no plan of care for anticoagulant (AC) medication. Resident #81 had no plan of care for anticoagulant (AC) medication. The findings include: 1. The facility staff failed to develop and implement a comprehensive care plan for anticoagulant therapy and diabetic management, including insulin therapy. Resident #23 was admitted to the facility with diagnoses that included COVID 19, hemiplegia/hemiparesis, chronic AFIB, DM2, cognitive communication deficit, and aphasia. The MDS (minimum data set -cms assessment tool) dated 09/05/22 was the 5 day admission assessment, which documented Resident #23 as moderately impaired cognitively for daily decision making with a score of 8 out of 15. Under Section N - Medications, the MDS documented that Resident #23 received insulin and anticoagulant medications, which are classified as high risk medications. Resident #23 clinical record was reviewed on 11/01/2022. Observed on the order summary report were the following orders: Apixaban Tablet 5 mg (milligrams) Give 1 tablet by mouth two times a day for DVT prevention. Order Date 10/5/2022 Insulin Glargine-yfgn 100 Unit/ML Solution Pen-injector. Inject 30 unit subcutaneously one time a day for DM 2. Order Date 10/12/2022. Insulin Lispro (1 Unit Dial) Solution Pen-injector 100 Unit/ML. Inject 4 unit subcutaneously four times a day for Diabetes Order Date 10/25/2022. Resident #23's medication administration records (MAR) for October and November 2022 were reviewed and documented the resident received the anticoagulant, Apixaban and both insulin (Glargine-yfgn & Lispro) as ordered/scheduled. Resident #23's comprehensive care plan (CCP) was reviewed, but had no individualized plan of care for anticoagulant (AC) medication or diabetic management, including insulin administration. On 11/02/2022 at 11:25 a.m., the licensed practical nurse (LPN #2) who routinely provided care for Resident #23 was interviewed regarding the resident's medications and care plans. LPN #2 reviewed Resident #23's clinical record and stated the resident was currently receiving both the anticoagulant and insulin. When asked why these serious medications were not included in the care plan, LPN #2 stated that the unit manager was responsible for the care plans. On 11/02/2022 at 11:30 a.m., the unit manager (LPN #3) was interviewed regarding the inclusion of high risk medications in the care plan. LPN #3 reviewed the clinical record and stated, Yes, there should be care plans for both the anticoagulant and insulin medications. I'm not sure why they were not included. On 11/02/2022 at 5:39 p.m., the above findings were reviewed during a meeting with the administrator, DON, ADON, and corporate staff. No further information was provided that indicated that the facility had provided care planning for either of the high risk medications or the diabetes management. 2. The facility failed to address the individualized need for anticoagulant medication in Resident #80's comprehensive care planning. Resident #80 was admitted to the facility with hypertension, DM2, hemiplegia/hemiparesis, AFIB, muscle weakness, and dysphagia. The minimum data set (MDS) dated [DATE] was the 5-day admission assessment, which documented Resident #80 with severely impaired cognition for daily decision making, with a BIMS (Brief Interview for Mental Status) score of 6 out 15. Under Section N - Medications, the MDS documented Resident #80 received anticoagulant medication, which has increased risk of bleeding. Resident #80's clinical record was reviewed on 11/01/022. Observed on the the order summary report was the following order: Apixaban Tablet 5 MG (milligrams) Give 1 tablet via J-Tube two times a day for cva via peg tube. Order Date 09/16/2022. Resident #80's medication administration records for September through November 2022 were reviewed and documented the resident received the anticoagulant medication, Apixaban as ordered/scheduled. Resident #80's care plans were reviewed, but had no plan of care for anticoagulant (AC) medication. On 11/02/2022 at 11:25 a.m., the licensed practical nurse (LPN #2) who routinely provided care for Resident #80 was interviewed regarding the resident's medications and care plans. LPN #2 reviewed Resident #80's clinical record and stated the resident was currently receiving the anticoagulant. LPN #2 stated the unit manager was responsible for the care plans. On 11/02/2022 at 11:30 a.m., the unit manager (LPN #3) was interviewed regarding the care plans. LPN #3 reviewed the clinical record and stated, Yes, there should be a care plan for the anticoagulant medications. I'm not sure why it was not included. On 11/02/2022 at 5:39 p.m., the above findings were reviewed during a meeting with the administrator, DON, ADON, and corporate staff. No other information was provided that care planning had been developed/implemented, in accordance with the MDS, to address the resident-centered need for anticoagulant medication. 3. The facility staff failed to include the physician ordered anticoagulant medication in Resident #81's comprehensive care plan. Resident #81 was admitted to the facility with diagnoses that included pneumonia, hypoxia, acute kidney failure, DM2, perforation of intestine, congestive heart failure and hypertension. The minimum data set (MDS - cms assessment tool) dated 10/03/2022 was the 5-day admission assessment and assessed Resident #81 as cognitively intact for daily decision making with a score of 13 out of 15. Under Section N - Medications, the MDS documented Resident #81 received anticoagulant medication, which has increased risk of bleeding. Resident #81's clinical record was reviewed on 11/01/022. Observed on the the order summary report was the following order: Apixaban Tablet 2.5 MG (milligrams) Give 2.5 mg by mouth two times a day for a-fib. Order Date 10/20/2022. Resident #81's medication administration records for October and November 2022 were reviewed and documented the resident received the anticoagulant medication, Apixaban as ordered/scheduled. Resident #81's comprehensive care plans were reviewed, but had no plan of care to address the individualized need for anticoagulant (AC) medication or the associated risk factors of this physician ordered therapy. On 11/02/2022 at 11:25 a.m., the licensed practical nurse (LPN #2) who routinely provided care for Resident #81 was interviewed regarding the resident's medications and care plans. LPN #2 reviewed Resident #81's clinical record and stated the resident was currently receiving the anticoagulant. When asked about care planning for this high risk medication, LPN #2 stated the unit manager was responsible for the care plans. On 11/02/2022 at 11:30 a.m., the unit manager (LPN #3) was interviewed regarding the care plans for the high-risk medications. LPN #3 reviewed the clinical record and stated, Yes, there should be a care plan for the anticoagulant medications. I'm not sure why it was not included. On 11/02/2022 at 5:39 p.m., the above findings were reviewed during a meeting with the administrator, DON, ADON, and corporate staff. No other evidence was presented that a plan of care for anticoagulant medication had been developed or implemented for Resident #81. 4. The facility staff failed to develop and implement a CCP (comprehensive care plan) to include measurable objectives and timeframes for Resident #78 in the area of pain management. Resident #78's diagnoses included, but were not limited: diverticulitis, atrial fibrillation, depression, muscle weakness, dysphagia, abnormal gait, polyneuropathy, history of falls, and musculoskeletal mastoid bone pain. The resident #78's most recent MDS (minimum data set - cms assessment tool) was an admission assessment dated [DATE]. This MDS assessed the resident with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating the resident was intact for daily decision making skills. This MDS did not assess the resident with having pain and pain was not triggered in the CAAS (care area assessment summary) section of this MDS. Resident #78 was interviewed on 11/02/22 at approximately 7:55 AM. Observed grimacing, Resident #78 had stated that she was in pain and had not slept the night before due to pain. Resident #78 stated that she has been having pain and has scheduled pain medications, but did not get the pain medication as ordered. Resident #78's clinical record was reviewed and included the following physician's order: Observation: Pain- observe every shift .start date: 08/21/22 . Further review of Resident #78's physician orders revealed that a lidocaine pain patch for hip pain was started on 10/11/22, Tylenol was started on 10/17/22, and the narcotic pain medication (indicated for moderate to severe pain) hydrocodone-acetaminophen 5-325 for mastoid bone pain was started on 10/17/22. Resident #78's current CCP (comprehensive care plan) was reviewed and revealed that the resident did not have a pain care plan developed until 11/01/22, although the resident was experiencing pain, receiving pain treatments, and had been admitted with pain diagnoses. The CCP documented, .Pain Management Date initiated: 11/01/22 resident will demonstrate and verbalize knowledge of strategies for pain management: pain management date initiated: 11/01/22 .Medication management date initiated: 1/01/22 .Resident will be offered non-pharmacological interventions for pain including distraction, entertainment/activity, food and fluids offered and/or repositioning date initiated: 11/01/22 . There was no evidence in the resident's clinical record that Resident #78 had any other care plan related to pain prior to 11/01/22. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), ADON (assistant director of nursing) and the corporate nurse were made aware in a meeting with the survey team. The DON was asked why was Resident #78's pain care plan just added on 11/01/22. The DON replied that she did not update or review the care plan and wasn't sure. No further information and/or documentation was provided prior to the exit conference to evidence that a pain care plan was developed for Resident #78 prior to 11/01/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Facility staff failed to assist Resident #62 with wearing the physician ordered TED (thrombo-embolic deterrent) hose. On 11/02/2022 at approximately 9:30 a.m., Resident #62 was observed in her room. She was dressed for the day. No TED hose were observed. She was asked if she had white stockings that staff helped her put on in the mornings and took off in the evenings. She stated, No, I don't have that. She was asked if she had any stockings in her drawers. She opened her drawers and stated, No, I don't have any. CNA (certified nursing assistant) #1 was in the hallway. She confirmed that she was assigned to Resident #62. She was asked about the physician ordered TED hose. She stated, I didn't help her get dressed today, the nurse did. I don't know if she is supposed to be wearing TED hose or not. She was asked if she had reviewed Resident #62's [NAME] (daily care guide) prior to caring for her. She stated, I haven't looked at it recently .the nurses tell us what we are supposed to do .I think they put those on the residents anyway. Resident #62 was admitted to the facility with hypertension, artherosclerotic heart disease, sick sinus syndrome, presence of cardiac pacemaker, diabetes mellitus, cognitive impairment, and a history of falls. A quarterly MDS (minimum data set - cms assessment tool), with an ARD (assessment reference date) of 10/07/2022, assessed Resident #62 having a BIMS (Brief Interview for Mentals Status) score of 5/15, indicating moderately impaired cognition with daily decision making. Resident #62's clinical record was reviewed on 11/01/2022 at approximately 2:30 p.m. Review of the physician orders included the following orders written on 09/19/2022: Apply TED hose daily to BLE (bilateral lower extremities). Nursing staff to assist her with this task, one time a day for edema. Remove TED hose @ HS (hour of sleep) Nursing staff to assist with this task, one time a day for edema. The unit manager, RN (registered nurse) #1 was interviewed at approximately 9:45 a.m. When asked who was supposed to assist Resident #62 with her TED hose, RN #1 stated, The CNAs do that. When told that Resident #62 did not have her TED hose on, nor were there any in her room that the resident could find, RN #1 stated, They may be in the laundry, but there should be a spare pair in the room. The comprehensive care plan and the [NAME] were reviewed at approximately 10:15 a.m., the TED hose were not observed on either. At approximately 11:30 a.m., RN #1 came to the conference room and stated, [Resident #62's] TED hose did go to the laundry this morning, but there should have been a spare in there for her. RN #1 was asked how the CNA would know to apply the TED hose since they were not on the resident's [NAME]. RN #1 stated, It was on the nurse's MAR (medication administration record), it should have been on the TAR (treatment administration record) .the nurse tells the CNA to assist the resident, but it should be on the care plan and the [NAME]. The above information was discussed with the administrator, the DON (director of nursing), the ADON (assistant director of nursing) and three corporate staff during an end of the day meeting on 11/02/2022 at approximately 5:30 p.m. No further information was obtained prior to the exit conference on 11/03/2022. Based on resident interview, staff interview, clinical record review, facility document review, the facility staff failed to provide ongoing wound assessments to monitor healing progress for one of 21 residents in the survey sample (Resident #34) and failed to follow physician's orders for applying TED hose for one of 21 residents in the survey sample (Resident #62). The findings include: 1. A complaint investigation was conducted on 11/01/22 through 11/03/22. An allegation within the complaint alleged that the facility failed to monitor for appropriate wound healing. Resident #34's diagnoses included, but were not limited to: HTN (high blood pressure), CHF (congestive heart failure), schizophrenia, asthma, Parkinson's disease, anxiety disorder, polyneuropathy, obesity, and depression. The most current MDS (minimum data set - cms assessment tool) was a quarterly review, dated prior to the discovery of the resident's wound on 07/29/22. This MDS documented the BIMS (brief Interview for Mental Status) score of 12 out of 15, indicating Resident #34 had moderate cognitive impairment in daily decision making skills. Resident #34's physical function was assessed as non-ambulatory and requiring extensive to full assistance of two staff for ADL's (activities of daily living). Resident #34's most recent full MDS (minimum data set - cms assessment tool) assessment was an annual assessment dated [DATE], which triggered in the CAAS (care area assessment summary) section for pressure ulcers, indicating the need for care plan development in this area. Resident #34's clinical records were reviewed and revealed that bilateral 'friction' wounds to the dorsal area of both feet (from shoes) were documented on a 07/29/22 weekly skin assessment. A physician progress note documented the following: .08/01/22 .seeing the resident for reports that he has abrasions to the tops of both of his feet with odor. Over the weekend, nursing staff reports that his shoes were rubbing the tops of his feet .rubbed the first layer of skin off .nursing staff have been covering with nonstick piece of gauze and tape however nursing staff reports that today it is draining .and odorous. Resident denies pain or any other acute concerns regarding this today .wearing nonskid socks instead of shoes since these abrasions started .dorsal aspects of both feet with 1st layer of skin sloughed off due to friction from his shoes .underlying skin is pink and moist with small amount of drainage on dressing .I have ordered for nursing staff to cleanse the wounds with DWC (dermal wound cleanser), apply TAO (topical antibiotic ointment), cover with nonstick gauze, and tape/wrap until healed. Due to yellow drainage and odor, I have ordered cephalexin 500 mg (milligrams) 3 times daily for 7 days .continue to keep shoes off .until wounds heal .signature of NP (Nurse Practitioner). A review of the physician's orders were revealed the following: .Cleanse .with DWC, apply TAO, cover with nonstick gauze until healed (order date: 08/01/22). The above order was changed on 08/03/22 to the following: .Cleanse .bilateral feet with DWC, apply collagen and calcium alginate, wrap with kerlix, Change QD [every day] every day shift for bilateral foot wounds .(start date: 08/03/22). The resident's MARs/TARs (medication/treatment administration records) for August 2022 were reviewed and revealed that the resident did receive the above treatments as ordered, but no documentation included wound monitoring or assessments. On 11/01/22 at 12:01 PM, Resident #34 was interviewed regarding his foot/feet wound(s) and was asked what had happened to cause the wounds. Resident #34 stated that he didn't know what happened to either foot, then stated that he doesn't walk. When questioned about wound care, Resident #34 stated that staff was cleaning and dressing it once a day, adding that he dreaded them doing it, but he did let them do it. When asked if he refused care at times, Resident #34 stated that he did not refuse care to the wounds on his feet and that the staff was taking care of them. When questioned if he had any problems with his feet before going to the hospital in August, Resident #34 stated that he didn't know. On 11/02/22 at 2:40 PM, an interview was conducted with the NP, regarding the wound development and treatment for Resident # 34. The NP stated that the resident started out with friction wounds from his shoes, for which she stated that she treated the resident with Keflex and wound care. The NP stated that the wounds seemed fine until one of the nurse's had notified another provider when maggots were found in the wound and the resident had been sent out to the hospital. The NP was then made aware that no wound assessments could be found or any evidence that the wound progress or treatment effective was being monitored. The NP was made aware that according to documentation, the wound treatments were completed, but there were no assessments documenting what the wounds looked like, during the dressing changes, on any of the days leading up to resident #34's transfer to the hospital on [DATE]. The NP replied that she would expect them (nursing staff) to look at it and document what they saw, not necessarily measure each time, but would expect them to document wound drainage, odor, and to document specifically what they did and of what they saw during the dressing change each day. On 11/02/22 at approximately 6:15 PM, the administrator, DON (director of nursing), and corporate nurse were made aware of the complaint allegations regarding Resident #34 and that no wound assessments to monitor wound progress could be found after the initial wound assessment by the NP, which was completed on 08/01/22. Their assistance was requested in locating any ongoing wound assessments, since that date. A policy on wound care and assessments was also requested at that time. On 11/03/22 at approximately 8:15 AM, the DON presented wound policy and procedure documents. The policy documented, .Documentation of Wound Treatments .the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment .type of wound .location .stage if pressure .if non-pressure (partial or full thickness) .measurements .description of wound characteristics .color .type of tissue .presence, amount, and characteristics of wound drainage .presence or absence of odor .presence or absence of pain .notification to physician and/or responsible party regarding wound or treatment changes . The DON also presented a weekly wound assessment dated [DATE], which only documented that the resident had an open area that was abraded to both feet from shoes. The other wound assessment dated [DATE] only documented that the resident had an open area. No other information was on this assessment, now were any other wound assessments presented. No further information and/or documentation was presented prior to the exit conference on 11/03/22 at 11:30 AM to evidence that the facility staff completed ongoing wound assessments to appropriately monitor Resident #34's wound healing. This is a complaint deficiency.

Based on observation, staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to provide timely treatment for an UTI (urinary tract infection) for one of twenty-one residents, Resident #28. The findings include: Resident #28 was admitted to the facility with the following diagnoses including but not limited to: Diabetes mellitus, quadriplegia, contracture of the left hand, UTI, and chronic kidney disease. An annual MDS (minimum data set -cms assessment tool) dated 09/02/2022 documented the BIMS (Brief Interview of Mental Status) score as 15 out of 15, indicating Resident #28 was cognitively intact for daily decision making. On 11/01/2022 beginning at approximately 3:00 p.m., a review of the clinical record included progress notes with the following entries: 10/29/2022 22:20 (10:22 p.m.) Positive for UTI. Spoke with [Name redacted]; place PICC line begin ertapenem 1 GM (gram) q (every) 24 hours. 10/31/2022 (Note from nurse practitioner signed 10/31/2022 at 7:51 p.m.) .Infection and inflammatory reaction due to indwelling urethral catheter .urine culture came back with E. Coli and Pseudomonas. She is on trimethoprim 50 mg daily for UTI prophylaxis, however, she has developed a UTI again. She should continue ertapenem 1 g daily until 11/4/2022. Foley care should be performed every shift and the catheter should be changed every 28 days . 11/01/2022 01:27 (a.m.) Ertapenem Sodium Reconstituted 1 GM Use 1 gram intravenously one time a day for UTI over 4 days. IV therapy to begin tomorrow 11-1 @1700 per MD order, noted change in (computer system) as well. Resident #28 had been observed in her chair during initial tour on 11/01/2022 at approximately 12:00 p.m. No IV line was observed at that time. At approximately 5:00 p.m., Resident #28 was again observed sitting up in chair in her room. When asked if she was getting IV antibiotics for a urinary tract infection, Resident #28 stated, I am supposed to be but I haven't gotten any yet .they said they don't have any needles .I had one, I think it was last week, it started bleeding and they took it out. When asked if she was having any lower abdominal discomfort or any symptoms related to her UTI, Resident #28 stated, No, I'm okay right now. On 11/01/2022 at approximately 5:10 p.m., LPN (licensed practical nurse) #7 was in the hallway preparing medications. When asked if she was taking care of Resident #28, LPN #7 stated, Yes. When asked about Resident #28's IV antibiotics for her urinary tract infection, LPN #7 looked at the MAR (medication administration record) and stated, The order says to start that tomorrow (11/02/2022). When asked why it wasn't being started until 11/02/2022, when it was ordered on 10/29/2022, LPN #7 stated, We are waiting for the pharmacy to send us the supplies to do it. When asked to explain what she meant by supplies, LPN #7 stated ,We need the antibiotic and the supplies to start the IV. On 11/02/2022 at approximately 9:10 a.m., a review of the clinical record included a change in condition note, which contained the following and was written by the unit manager, RN (registered nurse) #1: 11/02/2022 08:56 (a.m.) Change in Condition .nursing observations, evaluation, and recommendations are: Resident presents with UTI, Foley catheter in place. Treatment with Ertapenem 1 Gm IV X (times) 4 days . On 11/02/2022 at approximately 9:30 a.m., RN #1 was interviewed. Referring to the change in condition note that she had written earlier that day, RN #1 was asked if she was aware that the antibiotics for Resident #28 had not yet been started. RN #1 looked at the physician orders and stated, Yes, it starts this evening. She was referred back to the progress notes from 10/29/2022, 10/31/2022, and 11/01/2022, regarding Resident #28's orders for an IV antibiotic and the entry in the medical record for a PICC line insertion. RN #1 reviewed the record and stated, We don't do PICC lines here .but for a four day course of antibiotics she wouldn't need a PICC. We could use a regular IV. When asked how long it took for a medication to arrive from the pharmacy, since the antibiotic had been ordered on 10/29/2022 and the resident had still not received a dose, RN #1 stated, I don't know why she hasn't gotten her antibiotic. Ertapenem is something we have here in stock and we have everything we need to start an IV. RN #1 stated that she would look into a few things and get back to the survey team. At approximately 11:30 a.m., RN #1 came to the conference room and stated, The antibiotic order was written by the on-call physician over the weekend. It looks like the original order was written on October 29 to place a PICC line and discontinue it when the antibiotics were complete. That order was discontinued. There was also an order written on October 29 for the antibiotics to be given for four days .that was discontinued and rewritten to start on November first .that order was discontinued on November 1st, the reason on the order was 'waiting on IV supplies from the pharmacy', but they were suppose to be here today .I don't know what happened .some of the notes say we were waiting on the medicine, some say waiting on IV supplies. It looks like we ordered the medicine from the pharmacy .we have that antibiotic here so it could have been started .I spoke with the nurse practitioner and we got the order clarified so we can give it IM starting today at noon. When asked if the physician or nurse practitioner had been notified that the medication had not been given before today, RN #1 stated, There isn't any documentation that notification occurred, I don't feel like that happened. When asked if the nurses had changed/canceled the orders and the start dates of the antibiotic without speaking with the physician or the nurse practitioner, RN #1 stated, Yes, that is what I think happened .the physician should have been notified. On 11/02/2022 at approximately 3:30 p.m., the nurse practitioner (NP) was interviewed. When asked if she was aware that Resident #28 had not received any doses of her antibiotics prior to the IM injection ordered earlier on 11/02/2022, the NP stated, I was told on Monday (10/31/2022) that she had an IV and that it had infiltrated .I can't tell you the nurses name who told me that, but she said there weren't any needles here to restart it and they would have to come from the pharmacy .I thought she had gotten one dose and it would resume the next day [11/01/2022]. I found out today that none had been given, so we changed the route to IM. On 11/02/2022 at approximately 4:00 p.m., RN #1 was asked if other than the clinical record there was any place the nurses could have documented that the antibiotic was not given and the physician/nurse practitioner were notified. RN #1 stated, There is a physician book. RN #1 went to the nurse's station and looked in the book, but stated, There's not any documentation in here about that. On 11/02/2022 at approximately 4:30 p.m., the DON (director of nursing) came to the conference room and stated, Here is the packing slip from the pharmacy .the antibiotics have been here the whole time .they were ordered and the pharmacy dispensed them on the 30th [10/30/2022] and they were delivered on the 31st [10/31/2022] As a matter of fact, the pharmacy delivered them twice. The bags are in the bottom drawer of the med cart. When asked why the nurse had documented that the meds were not available, the DON stated, I don't know, she is not here and we have labeled her as DNR. When asked what DNR meant, the DON stated, Do not rehire. The above information was discussed with the DON, the administrator, the ADON (assistant director of nursing) and three members of the corporate staff. Concerns were voiced that an IV antibiotic had been ordered on 10/29/2022 for four doses and the medication was not started until 11/02/2022. When asked if the physician or nurse practitioner had been notified of the delay in treatment, the DON stated that she would find out. When asked how the nurses know what meds were available in the Stat box, the DON stated that there was a list in each medication room. On 11/03/2022 at 9:30 a.m., the DON entered the conference room and was asked if she could clarify if the antibiotics were not started because the nurses thought the meds were in house or because they didn't know that IV supplies were in house. The DON responded, I've not been able to get in touch with the nurses .I don't know if the physician was notified or not, or if the problem was they didn't know we had the meds or if they thought the IV supplies weren't available.The DON then presented a list of medications available in the stat box, on which Ertapenem 1 gram was listed. No further information was obtained prior to the exit conference on 11/03/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and clinical record review, the facility staff failed to obtain physician orders to provide ongoing assessment and care for a colostomy for one of twenty residents in the survey sample. Resident #17 had no current physician orders for care the colostomy and no evidence of daily colostomy site assessments as documented in the comprehensive care plan. The findings include: Resident #17 was admitted to the facility with diagnoses that included inflammatory bowel disease with colostomy, asthma, history of cerebral infarction, diverticulosis, atrial fibrillation, hypothyroidism, depression, anxiety, hypertension and chronic respiratory failure. The MDS (minimum data set - CMS assessment tool) assessment dated [DATE] documented the BIMS (Brief Interview of Mental Status) as indicating intact cognition for daily decision making. On 11/1/22 at 12:06 p.m., when interviewed about quality of care in the facility, Resident #17 stated that she provided care for her colostomy that included twice weekly flange changes. Resident #17 stated the aides assisted her to clean around the colostomy site during showers. Resident #17 stated nurses did not routinely look at the colostomy and she informed the nurses if she had any problems with the site. Resident #17's clinical record was reviewed and revealed no current physician orders regarding the care of the colostomy. The October 2022 treatment administration record (TAR) documented a previous order dated 11/4/20 for emptying of the colostomy bag once per shift with replacement as needed. This order was discontinued on 10/7/22. There were no current colostomy orders or treatments documented on the TAR from 10/8/22 through 10/31/22. There was no documentation regarding when the bag and/or flange were changed. A nursing note dated 10/10/22 documented, .PT [patient] needing assistance with stoma . The remaining Nursing notes from 10/11/22 through 10/31/22 made no further mention of the resident's colostomy. Resident #17's comprehensive care plan (revised 7/6/22) documented the resident had a colostomy, with goals to maintain proper function and prevent skin breakdown, along with interventions that included, Assess daily to make sure ostomy is functioning properly and stool is being diverted through ostomy. Notify MD [physician] of any complications .Change Ostomy bag per MD orders . On 11/2/22 at 2:37 p.m., the licensed practical nurse (LPN #2) caring for Resident #17 was interviewed about colostomy care. LPN #2 stated that the resident performed her own colostomy care. LPN #2 stated that the resident was specific about how the care was done and used supplies provided by the facility. LPN #2 reviewed the clinical record and stated that she found no current orders about care of the colostomy. LPN #2 stated that the resident was readmitted to the facility on [DATE] and the orders may not have been restarted upon readmission. LPN #2 stated that there were no current entries on the TAR about the colostomy. On 11/2/22 at 3:10 p.m., the unit manager (LPN #3) was interviewed about Resident #17's colostomy care. LPN #3 reviewed the clinical record and stated that there were no current orders for colostomy care. LPN #3 stated that she did not know why colostomy care orders were not initiated when the resident was readmitted on [DATE]. LPN #3 stated that the resident provided routine care of the colostomy and usually informed the nurses of any problems. LPN #3 stated that nurses should be monitoring the colostomy site for any complications. This finding was reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 11/2/22 at 5:40 p.m. No further information was provided prior to facility exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #78 was admitted to the facility on [DATE]. Diagnoses for Resident #78 included: Peripheral vascular disease, Gangrene, neuropathy, diabetes, and adult failure to thrive. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/10/21. Resident #78 was assessed with a cognitive score of 12 indicating cognitively intact. On 4/6/21 review of Resident #78's current MDS section J1550 documented Yes for dehydration. On 04/07/21 at 8:00 AM, MDS coordinator, registered nurse (RN #4 ) was interviewed regarding Resident #78's trigger for dehydration. RN #4 reviewed the medical record and said that Resident #78 was triggered due to an elevated BUN (blood urea nitrgen) indicating dehydration, and was placed on IV fluids on 3/4/21. She stated a care plan should have been developed to monitor for prevention of dehydration for Resident #78. On 04/07/21 at 4:00 PM, the administrator and DON (director of nursing) were informed of the above finding. On 04/08/21 at 08:40 AM, RN #4 stated after looking back at the dates when Resident # 78 was given intravenous fluids she had been off work and that was why a care plan did not get put into the system. No other information was presented prior to exit conference on 4/8/21. Based on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for two of twenty residents in the survey sample, Residents #37 and #78. Resident #37 had no care plan developed regarding communication. Resident #78 had no plan of care for dehydration prevention. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #37 included end stage renal disease, atrial fibrillation, GERD (gastroesophageal reflux disease), hypertension, congestive heart failure, anxiety, depression, glaucoma, irritable bowel syndrome and restless leg syndrome. The minimum data set (MDS) dated [DATE] assessed Resident #37 with moderately impaired cognitive skills. On 4/6/21 at 10:54 a.m., Resident #37 was observed in the hall near her room talking with two staff members. Resident #37 was non-English speaking. On 4/6/21 at 11:20 a.m., a staff member was with Resident #37 in her room using a cell phone to translate the resident's conversation. Resident #37's plan of care (revised 3/24/21) included no problems, goals and/or interventions regarding language and/or communication. On 4/7/21 at 11:20 a.m., the registered nurse (RN #3) unit manager was interviewed about Resident #37's care plan. RN #2 stated an interpreter service was available by telephone to assist with language interpretation with Resident #37. RN #2 stated there was a certified nurses' aide in the facility that spoke Resident #37's language and the resident's family assisted staff with communications with the resident. RN #3 reviewed the plan of care and stated she did not see any plan regarding language/communication. On 47/21 at 11:25 a.m., RN #2 responsible for MDS and care plan development was interviewed about a communication plan for Resident #37. RN #2 the social worker was responsible for developing plans regarding communication. RN #2 reviewed Resident #37's care plan and stated there was nothing in the plan about communication and/or language. This finding was reviewed with the administrator and director of nursing during a meeting on 4/7/21 at 4:10 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/7/2021 at 07:35 AM, during medication administration, licensed practical nurse (LPN) #1 was observed gathering medications and supplies and proceeding to a resident's room without locking the medication cart. Another resident (Resident #81) was sitting in a wheelchair next to the medication cart. On 4/7/2021 at 07:50 AM, LPN #1 was observed again leaving the medication cart unlocked and proceeding to a resident's room for medication administration, then returning to lock the cart after getting approximately 30 feet away. On 4/7/2021 at 8:10 AM, LPN #1 was made aware of concerns with the medication administration observation and LPN #1 stated I know, I forgot to lock my cart. A review of the facility's policy Security of Medication Cart dated April 2007 documented, Medication carts must be securely locked at all times when out of the nurse's view. A review of Resident #81's minimum data set (MDS) was a quarterly assessment with an assessment review date (ARD) of 3/12/2021 and assessed Resident #81 with a cognitive score of 06 indicating severe cognitive impairment. Resident #81's comprehensive care plan (CCP) identified impaired safety awareness and wandering in other resident's rooms and taking belongings. On 4/6/2021 at 11:30 AM, Resident #81 was observed pilfering in the trash can behind the nurse's station requiring redirection by the nurse. On 4/8/2021 at 8:55 AM, Resident #81 was observed in the hallway attempting to open a door with a combination lock on it. On 4/8/2021 at 9:00 AM, the director of nursing (DON) was interviewed regarding the medication cart being left unlocked. The DON stated that locking the medication cart is an expectation when it is unattended. The DON also stated that while Resident #81 has not attempted to open any of the cart drawers in the past, he routinely requires redirecting due to a lack of safety awareness. No further information or documentation was provided prior to the exit conference on 4/8/2021 at 11:00 AM. Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a safe bed environment for one of 20 residents (Resident #60); and failed to ensure a medication cart was locked and secure in a resident care area on one of two nursing units (Unit 2). Findings include: 1. Resident #60 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, COPD (chronic obstructive pulmonary disease), affective mood disorder, cognitive communication deficit, hypertension, seizures, depression, heart failure and hyperlipidemia. The minimum data set (MDS) dated [DATE] assessed Resident #60 with severely impaired cognitive skills and as requiring the extensive help of two people for bed mobility and transfers. On 4/7/21 at 8:47 a.m., Resident #60's room and bed was inspected. U-shaped bed rails were in the up position on both sides of the bed near the head of the bed. Resident #60's clinical record documented the resident experienced a seizure on 2/11/21. A nursing note dated 2/11/21 documented, Res [Resident] appeared to have a seizure at 1725 [5:25 p.m.]. Aide brought res tray and res 'screamed out and starting shaking.' This nurse ran into room and res appeared to be post epileptic . A change in condition form dated 2/11/21 documented, .CNA [certified nurses' aide] called nurse into room after hearing [Resident #60] scream. She was then observed to begin shaking .nonverbal and teary .In bed in low position . Resident #60's clinical record documented a Bed Rail Safety Review dated 3/16/21 documenting the resident was not recommended for bed rails due to safety concerns. The bed rail form documented the resident had seizures, dementia, exhibited impulsive behaviors that placed her at risk for accidents, was disoriented at all times and had experienced a fall in the last 6 months. This form documented the resident was not able to get in/out of bed safely on her own and there was a possibility that the resident may climb over a bed rail if in place. An alternative to the bed rail was listed on the form as adjustable height low bed. The form documented the low bed height was recommended for Resident #37 instead of bed rails. Resident #60's plan of care (revised 4/7/21) documented the resident had a seizure on 2/11/21 and was at risk of falls due to weakness, loss of balance, attempts to transfer self to and from bed and dementia with severe cognitive impairment. Interventions to prevent injuries included low bed and providing a safe environment. On 4/7/21 at 11:42 a.m., the registered nurse unit manager (RN #3) was interviewed about bed rails in place on Resident #60's bed. RN #3 stated she completed the bed rail review on 3/16/21. RN #3 stated the resident was recommended for a low bed without rails. RN #3 stated rails were not recommended for Resident #37 because she threw her legs over the side of the bed at times, had dementia and recently experienced a seizure. RN #3 stated she did not realize the grab rails were considered bed rails. On 4/8/21 at 7:18 a.m., Resident #60 was observed in bed with her eyes closed. U-shaped rails were in the raised position on both sides of the bed. Resident #60 was observed again in bed with both bed rails raised on 4/8/21 at 8:00 a.m. These findings were reviewed with the administrator and director of nursing during a meeting on 4/7/21 at 4:10 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to assess one of twenty residents in the survey sample prior to the use of bed rails. Resident #64 had bed rails in use without a prior assessment for safety, attempted alternatives or informed consent regarding risks/benefits of the rails. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction with left sided hemiplegia and hemiparesis, dysphagia, depression, aphasia, vascular dementia, dysarthria, lymphoma and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #64 with moderately impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility and total assistance of two people for transfers. On 4/6/21 at 3:00 p.m., Resident #64 was observed in bed with u-shaped bed rails up on both sides of the bed. The rails were located near the middle of the bed at the area of the resident's waist. Resident #64 was observed again on 4/6/21 at 4:00 p.m., 4/7/21 at 7:48 a.m. and on 4/7/21 at 2:16 p.m. in bed with rails up. Resident #64's clinical record documented no assessment for bed rail safety. There were no documented attempted alternatives to the bed rails and no informed consent from Resident #82's responsible representative regarding risks and benefits of the rails. Resident #64's clinical record documented the resident had an unwitnessed fall from the bed on 3/16/21. A nursing note dated 3/16/21 at 8:23 p.m. documented, Patient was found lying in the floor beside of his bed. It appears he had been reaching for something on his bedside table .does have two 2 cm [centimeters] x 2 cm hematomas on his scalp. Also has a 1 cm x 1 cm reopened area on he [the] left side of his scalp . The clinical record documented no assessment for bed rail safety following the unwitnessed fall on 3/16/21 and post-fall interventions made no mention of bed rail use. On 4/7/21 at 11:46 a.m., the registered nurse unit manager (RN #3) was interviewed about a bed rail assessment for Resident #64. RN #3 stated, I haven't done a bed rail assessment on him [Resident #64] recently. RN #3 stated the resident had grab bars on each side of the bed and she did not realize the grab bars were considered bed rails. RN #3 stated again that she was not aware the grab bars were considered rails and therefore no safety assessment or informed consent were obtained. This finding was reviewed with the administrator and director of nursing during a meeting on 4/7/21 at 4:10 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure one of twenty residents was free from unnecessary medication. Resident #82 had a physician's order for the psychotropic medication lorazepam as needed (prn) for greater than 14 days without a documented rationale for the extended duration of the prescription. The findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included anxiety, Alzheimer's, dementia with behavioral disturbance, lumbar disc degeneration, cognitive communication deficit, diabetes and major depressive disorder with psychosis. The minimum data set (MDS) dated [DATE] assessed Resident #82 with short and long-term memory problems and severely impaired cognitive skills. Resident #82's clinical record documented a physician's order dated 3/30/21 for lorazepam 0.5 milligrams (mg) with instructions to give 1 tablet every 8 hours as needed for agitation until 5/31/21. The clinical record documented no rationale for why the prn (as needed) lorazepam order was required for over 60 days instead of the 14-day limit. A nurse practitioner note dated 3/30/21 documented recent medication changes and stated, .was started on melatonin 3 mg at bedtime with an order to repeat the dose between 1 and 3 AM if she was still a pacing. According to nursing records she has only needed 1 - 2 doses of lorazepam in the last week or so, and it appears that she has been resting through the night according to nursing notes . (Sic) There was no mention of why the prn lorazepam order was extended beyond the 14-day limit. On 4/7/21 at 11:30 a.m., the registered nurse unit manager (RN #3) was interviewed about Resident #82's prn lorazepam. RN #3 reviewed the clinical record and stated she did not see anything documented by the nurse practitioner about why the order was extended beyond 14 days. RN #3 stated melatonin was ordered to be used before the lorazepam. On 4/7/21 at 4:15 p.m., the director of nursing (DON) was interviewed about Resident #82's prn lorazepam. The DON stated she talked with the nurse practitioner that ordered the prn lorazepam on 3/30/21. The DON stated the nurse practitioner wanted nurses to use the melatonin first instead of the lorazepam. The DON stated the nurse practitioner did not want to take away the lorazepam because the resident would be moving rooms soon due to remodeling/construction in the facility. The Nursing 2017 Drug Handbook on pages 902 describes lorazepam as a scheduled IV controlled anxiolytic used to treat anxiety and insomnia. Page 903 of this reference documents adverse reactions to lorazepam include drowsiness, sedation, agitation, dizziness, weakness, unsteadiness and hypotension. Under precautions is listed, Use cautiously in elderly, acutely ill, or debilitated patients . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 4/7/21 at 4:10 p.m. (1) [NAME], [NAME], [NAME] and [NAME]. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.

Based on observation, staff interview and facility document review, the facility staff failed to store food in a sanitary manner in the main kitchen. Findings include: An initial tour of the main kitchen was conducted on 04/06/21 at 10:30 AM with the DM (dietary manager). The dry storage area was observed. Four packs of unopened, soft tortilla shells were observed with an expiration date of 02/11/21. The expiration date was on the original (manufacturer's) packaging. The DM stated that she would dispose of them and wasn't sure why they were still in the dry storage area. A policy was requested on food safety and storage. On 04/06/21 at approximately 2:00 PM, a policy was presented. The policy, Food receiving and storage documented, .non refrigerated foods .will be in a designated dry storage unit .rotated using first in - first out .foods shall be received and stored in manner that complies with safe food handling practices . A food storage chart was provided for reference on shelf life; this food chart did not have a reference for soft tortillas. The DON (director of nursing) and the administrator were made aware of the above in a meeting with the the survey team on 04/07/21 at approximately 4:15 PM. No further information and/or documetnation was provided prior to the exit conference on 04/08/21.

Based on observation, staff interview and facility document review, the facility staff failed to ensure garbage and refuse were disposed of properly. Findings include: An initial tour of the main kitchen was conducted on 04/06/21 at 10:30 AM with the DM (dietary manager). On 04/06/21 at 11:00 AM, the garbage and refuse area and containers were observed. A sack of approximately 10 to 12 heads of cabbage were sitting outside of the dumpster on the ground. The DM was asked why it was on the ground and not in the dumpster. The DM stated that she did not know and opened the dumpster and picked up the sack with the cabbage heads and threw it into the dumpster. An empty milk carton was observed on the ground in front of the dumpster, as well a single latex glove. A policy was requested on garbage and refuse disposal and maintenance. On 04/06/21 at approximately 2:00 PM, a policy was presented. The policy, .Garbage and Rubbish Disposal documented, .All garbage and rubbish containing food wastes shall be kept in containers .Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin .storage areas will be kept clean at all times, and shall not constitute nuisance .outside dumpster's provided by garbage pickup services will be kept closed and free of surrounding litter. The DON (director of nursing) and the administrator were made aware of the above in a meeting with the the survey team on 04/07/21 at approximately 4:15 PM. No further information and/or documetnation was provided prior to the exit conference on 04/08/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 20 residents in the survey sample, Resident #9. Resident #9's electronic health record failed to indicate the resident's correct code status. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, end stage renal disease requiring dialysis, hyperlipidemia, hypothyroidism, muscle weakness and atrial fibrillation. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed Resident #9 as cognitively intact and independent for daily decision making with a score of 15 out of 15. Resident #9's electronic clinical record was reviewed on 04/06/2021. Observed on the resident information screen was the following: Code Status: Full Code Observed on the orders was the following: FULL CODE Active: 01/23/2020. Observed on the care plans was the following: [Resident #9] chooses to be a DNR (Do Not Resuscitate). Revision on: 03/23/2021) Observed in the electronic clinical record was a scanned copy of a Durable Do Not Resuscitate Order (DDNR) dated 03/23/2021. The physician and Resident #9 signed the DDNR order. On 04/07/2021 at 8:42 a.m. the licensed practical nurse (LPN #1) who routinely provides care for Resident #9 was interviewed regarding code status and what system did nursing use to verify code status. LPN #1 stated they use the resident information screen on the electronic health record and have a code status binder at the nursing station. LPN #1 was asked what Resident #9's code status was. LPN #1 stated, [Resident #9] is a Full Code and has been since she has been here. LPN #1 was asked what was the process for code status change. LPN #1 stated, normally the social worker gets the form signed, scans a copy into the electronic record, and then provides it to nursing so we can change the order and then we place it in the code status binder. LPN #1 stated, I can show you in the binder she (Resident #9) is a Full Code. Observed in the code status binder was the DDNR (Durable Do Not Resuscitate Order dated 03/23/2021. LPN #1 stated, I apologize I may not have been here when this changed so I am not sure who received the form, but they should have changed the order from Full Code to a DNR. On 04/07/2021 at 12:45 PM, the facility's social worker (OS #1) was interviewed regarding Resident #9's code status. OS #1 stated, Yes, I was aware of the change. I am responsible for getting the form signed, scanned into the electronic record, and to notify nursing so they can change the order. I don't remember who I gave the updated form too, but I don't think it was [LPN #1]. A copy should have been placed in the binder and the unit manager or the nurse on duty should have changed the order. These findings were shared with the administrator, the DON, and regional staff during a meeting on 04/07/2021 at 4:10 p.m.

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control protocols on one of two nursing units. A housekeeper failed to follow infection control protocols regarding personal protective equipment (PPE) on the A-wing quarantine unit. The findings include: On 4/6/21 at 12:32 p.m., a housekeeping employee (other staff #5) was observed exiting the quarantine unit through the zippered curtain. The housekeeper had on a mask, face shield, gown and gloves. The gown was not tied at the neck or waist, was loosely hanging and partially coming down as the housekeeper walked. The housekeeper went across the hall on the nursing unit and entered the dirty utility room located near the nursing station. The housekeeper immediately came out of the room wearing the same PPE and with a white wheeled cart re-entered the zippered quarantine unit. On 4/7/21 at 11:54 a.m., the registered nurse unit manager (RN #3) was interviewed about the quarantine unit. RN #3 stated the residents on the quarantine unit were on enhanced droplet precautions for 14 days because they were new admissions and this was part of the COVID-19 prevention protocols. RN #3 stated employees were supposed to remove and dispose of PPE prior to exiting the quarantine unit. On 4/7/21 at 12:15 p.m., the housekeeping supervisor (other staff #6) was interviewed about the housekeeper (other staff #5) exiting the quarantine unit wearing PPE. The supervisor stated the housekeeper was on the quarantine unit cleaning a resident room after a discharge. The supervisor stated the housekeeper was supposed to remove PPE and wash and/or sanitize hands prior to exiting the quarantine unit. The supervisor stated this housekeeper had been trained on when and how to wear PPE following cleaning of an isolation room. On 4/7/21 at 1:40 p.m., the registered nurse (RN #4) infection preventionist was interviewed about protocols on the quarantine unit. RN #4 stated the residents on the zippered quarantine unit were new admissions and were on enhanced droplet precautions for 14 days after their admission as part of COVID-19 prevention protocols. RN #4 stated all employees were to remove PPE (gowns, gloves and face shield) and perform hand hygiene prior to exiting the unit. On 4/7/21 at 2:00 p.m., the housekeeper observed on 4/6/21 (other staff #5) was interviewed about exiting the quarantine unit without removing PPE. The housekeeper stated, I was in a hurry. The housekeeper stated she was deep cleaning a room on the quarantine unit after a resident discharged . The housekeeper stated she did not touch anything and just went into the utility room to get a linen cart. When asked why she did not remove/dispose of the PPE prior to exiting the unit, the housekeeper stated, They needed the room so I was in a hurry. The housekeeping supervisor provided a copy of the facility's policy titled Isolation Room Cleaning (COVID-19 Emerging pathogens - undated). This policy documented steps for isolation room cleaning that included, .Sanitize your hands with hand sanitizer. Put on proper personal protective equipment (gown/gloves/mask) . This policy documented exit procedures after cleaning an isolation room as, While still inside the room, carefully remove the gown and gloves, but not the mask being careful to turn each item inside out as it is removed so as not to touch any of the clothing. Discard the protective clothing in the proper container within the room .Remove and dispose of gloves once all other PPE is removed and disposed of. Remove the mask outside the room and wash hands and sanitize following universal precautions with antibacterial soap . The housekeeping supervisor presented a copy of an in-service education conducted on 3/29/21 that included the housekeeper (other staff #5). This education documented the quarantine unit required protocols for enhanced droplet infection control precautions. The education included instructions for putting on and taking off PPE. The instructions for donning a gown included, .Put on gown outside room. Open-end faces your back. Tie the back of the gown . Instructions documented to remove/dispose of PPE and perform hand hygiene prior to leaving contaminated/quarantine area. This finding was reviewed with the administrator and director of nursing during a meeting on 4/7/21 at 4:10 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for two of 24 residents in the survey sample. 1. Resident #11 had no plan of care developed regarding a decline in bowel and bladder function. 2. Resident #15 had no care plan developed regarding emotional support/grief following the death of a family member. The findings include: 1. Resident #11 had no plan of care developed regarding a decline in bowel and bladder function. Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included anxiety, disc degeneration, Alzheimer's dementia, cataracts, cerebrovascular disease, osteoarthritis, history of breast cancer, dementia with behaviors, depression and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented a decline in bowel and bladder function starting in February 2019. MDS assessments dated 10/2/18 and 12/26/18 documented Resident #11 was always continent of bowel and bladder function with no episodes of incontinence noted. A bowel and bladder evaluation tool dated 1/10/19 documented Resident #11 with independent mobility, moderately impaired cognitive skills and as Mostly continent of bowel and bladder function. This evaluation documented the resident was a good candidate for a retraining program and rarely had episodes of incontinence unless she was acutely ill and weak. The quarterly MDS dated [DATE] documented a decline in bowel and bladder continence. Section H. of this MDS listed the resident was frequently incontinent of bowel (2 or more episodes of incontinence but at least one continent bowel movement in 7 day look back period) and occasionally incontinent of bladder (less than 7 episodes of incontinence). A bowel and bladder evaluation dated 4/10/19 listed the resident's health as stable with independent mobility and documented the resident as a good candidate for a retraining program. Resident #11's plan of care (revised 3/7/19) included no problems, goals and/or interventions regarding a decline in bowel and bladder function. The care plan listed the resident required assistance for activities of daily living, including toileting but made no mention of the resident's assessed frequent bowel incontinence and occasional bladder incontinence. On 5/22/19 at 10:10 a.m., the certified nurse's aide (CNA #1) routinely caring for Resident #11 was interviewed about the resident's bowel/bladder function. CNA #1 stated Resident #11 was mostly incontinent during the night. CNA #1 stated the resident ambulated on her own during the day and was mostly continent when awake. CNA #1 stated she was not aware of any interventions about the resident's bowel/bladder toileting. CNA #1 stated Resident #11 was not on any type of scheduled toileting plan. On 5/22/19 at 1:50 p.m., the licensed practical nurse (LPN #4) unit manager was interviewed about any plan of care regarding Resident #11's decline in bowel/bladder function. LPN #4 stated nothing had been initiated for Resident #11 regarding a toileting plan or program and therefore nothing had been added to the care plan. On 5/22/19 at 2:45 p.m., the registered nurse (RN #2) responsible for MDS and care plans was interviewed about Resident #11. RN #2 stated there had been no plan of care developed regarding incontinence for Resident #11. RN #2 stated the resident's last care plan meeting/review was 3/7/19 and staff members brought up nothing regarding a bowel/bladder decline. RN #2 stated care plans were developed based upon MDS assessments, morning staff meetings and resident care plan meetings. This finding was reviewed with the administrator and director of nursing during a meeting on 5/22/19 at 4:05 p.m. 2. Resident #15 had no care plan developed regarding emotional support/grief following the death of a family member. Resident #15 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, atrial fibrillation, hypothyroidism, major depressive disorder, anxiety, restless leg syndrome, high blood pressure and macular degeneration. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitive intact and feeling down, depressed and/or hopeless on most days. On 5/21/19 at 12:09 p.m., Resident #15 was interviewed about quality of life and care in the facility. Resident #15 stated she was frequently sad and was still upset about the recent death of her son. Resident #15 stated she did not talk and socialize with other residents in the facility and preferred to be alone. Resident #15's clinical record documented a nursing note dated 4/16/19 stating, .Resident was notified of son passing this AM, resident visited son before passing and was aware of his condition. Daughter came to visit after being notified to visit with mom. The clinical record documented no assessment of the resident in response to her son's death. There were no further nursing or social worker notes indicating any interventions and/or follow up with the resident regarding the death. Resident #15's plan of care (revised 3/10/19) included no problems, goals and/or interventions regarding the resident's grief and/or emotional needs related to death of her family member. On 5/22/19 at 3:36 p.m., the facility's social worker was interviewed about a plan of care regarding Resident #15's grief and possible emotional needs related to the death. The social worker stated she had visited Resident #15 since the son's death but did not document anything about it in the clinical record. When asked about a plan of care regarding the resident's grief process, the social worker stated, Anybody could add care plan items. The social worker stated she had added nothing to the care plan about Resident #15's grief or emotional needs regarding the son's death. On 5/22/19 at 4:00 p.m., the registered nurse (RN #2) responsible for MDS and care plans was interviewed. RN #2 stated the social worker was responsible for care plan items related to mood, behaviors and emotional health. RN #2 stated there was no plan of care developed regarding Resident #15's grief or emotional needs related to the death. These findings were reviewed with the administrator and director of nursing during a meeting on 5/22/19 at 4:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and staff interview the facility failed to review and revise a comprehensive care plan for one of twenty-four residents. Resident #64's care plan was not revised regarding code status. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included long-term use of anticoagulants, muscle weakness, dementia without behavioral disturbance, chronic a-fib, pain in right hip and lower back, hypertension, abnormal posture, and cognitive communication deficit. The most recent minimum data set (MDS) dated [DATE], was an annual assessment and assessed Resident #64 as severely cognitively impaired for daily decision making, having long and short term memory problems. Resident #64's clinical record was reviewed on 05/22/19 at 2:30 p.m. Observed on the physician orders was an order for a DNR (Do Not Resuscitate) dated 11/23/18. Additionally, observed was a completed DNR form dated 10/29/18 that was signed by the physician and Resident #64's daughter. Resident #64's care plans were reviewed and documented the following: Focus - Advanced Directives, Resident has the following Advanced Directives on record: FULL CODE. Date Initiated: 05/08/2017. Created by: [Social Worker]. On 05/22/19 at 2:47 p.m., the licensed practical nurse (LPN #2) who routinely provides care for Resident #64 was interviewed regarding the resident's code status. LPN #2 opened the electronic medical record (EMR) and stated the resident is a DNR. LPN #2 then said let me double check the code status binder. LPN presented the binder and it was observed in the binder a signed DNR dated 10/29/18 for Resident #64. LPN #2 was asked who would be responsible for updating the code status care plans and she stated the social worker or the MDS coordinator would update the care plans. On 05/22/19 at 2:57 p.m., the social worker (OS #1) was interviewed regarding Resident #64's code status care plan. OS #1 stated nursing usually notifies her and/or the MDS coordinator of code status changes and then she or the MDS coordinator would update the care plans. OS #1 continued and stated she completes audits on the code status binder every four to six weeks; however she had not been cross referencing the audits with the care plans. OS #1 stated she could not remember if she was notified of Resident #64's code status change, but she had completed the code status audits as scheduled and the care plan must have been overlooked and not updated. These findings were discussed during a meeting on 05/22/19 at 4:15 p.m., with the Administrator and Director of Nursing.

Based on observation, staff interview and facility document review the facility staff failed to follow professional standards of practice for one of 24 residents in the survey sample: Resident # 16. Resident # 16 was not instructed to rinse his mouth after administration of an inhaled corticosteroid medication. Findings include: On 5/22/19 beginning at 7:45 a.m. a medication pass and pour observation was conducted with LPN (licensed practical nurse) # 1. Resident # 16 had wheeled himself to the medication cart and asked for his medications. One of the medications administered to Resident # 16 was Symbicort 160/4.5, an inhaled medication for asthma and COPD. LPN # 1 stated He gets two puffs; I give one puff, then his oral meds, then the other puff. The resident was not encouraged or instructed after each puff to rinse his mouth and spit. During reconciliation 5/22/19 at 8:45 a.m. of the medications administered to Resident # 16 was a current order for Symbicort 160/4.5 2 puffs twice a day. On 5/22/19 at 9:00 a.m. the administrator was asked for a policy for inhaled medications or a copy of the package insert for the Symbicort. The administrator gave this surveyor a copy of the package insert which directed Dosage and Administration 2.1 .after inhalation, the patient should rinse the mouth with water without swallowing. On 5/22/19 at 10:25 a.m. LPN # 1 was asked about the resident's use of the Symbicort. LPN # 1 stated Well, he swallowed water with his meds after the first puff, and I told him to do oral care when he got back to the room. LPN # 1 further stated Resident # 16 was often demanding and wanting his medications when/how he wanted them. The administrator and DON were informed of the above findings during a meeting with facility staff 5/22/19 beginning at 4:05 p.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe transfer for one of 24 residents in the survey sample. The legs of a mechanical lift were not locked prior to transferring Resident #49 from his bed to a wheelchair. The mechanical lift turned over during the transfer with Resident #49 experiencing a skin tear on his nose as a result of the incident. The findings include: Resident #49 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #49 included quadriplegia, heart failure, history of kidney transplant, neuromuscular dysfunction of bladder, diabetes, depression, high blood pressure, diabetic neuropathy and sleep apnea. The minimum data set (MDS) dated [DATE] assessed Resident #49 as cognitively intact and as totally dependent upon two people for mobility and transfers. Resident #49's clinical record documented a nursing note dated 1/15/19 stating, At approximately 11:30 a.m. this nurse was called to patient's room. Patient found in his w/c [wheelchair], hoyer lift was on its' side on the floor and cross bar was being held away from patient's face. Blood noted on nose and face. Areas cleaned. Patient sustained a skin tear to bridge of nose. Measured and treated by wound nurse. Ice applied. Call place to spouse .NP [nurse practitioner] notified . (Sic) On 5/22/19 at 1:25 p.m., Resident #49 was interviewed about the lift incident of 1/15/19. Resident #49 stated three staff people were transferring him with the Hoyer lift from the bed to his wheelchair. Resident #49 stated the lift turned over during the transfer but he went into his wheelchair and did not fall in the floor. Resident#49 stated the swinging bar that attached to the lift hit him across the nose during the accident resulting in a skin tear. Resident #49 stated he was not sure what happened but thought the legs on the lift shifted when he was moved over the wheelchair causing it to turn over. Resident #49 stated the skin tear was treated and healed without problems but the incident was concerning as regards to safety of the lift. Resident #49's plan of care (revised 3/13/19) documented the resident was at risk of falls due to quadriplegia and required total assistance of two people for transfers. The care plan interventions to prevent falls and/or injury included keeping a safe environment, mechanical lift with assistance of two people for all transfers, call bell accessible and low bed position. Resident #49's last MDS assessment prior to the lift injury (dated 12/5/18) documented the resident weighed 246 pounds and was totally dependent upon staff for bed mobility and transfers. An investigation of Resident #49's lift incident was requested. On 5/22/19 at 1:40 p.m., the director of nursing (DON) presented a copy of a Skin Alteration Investigation form dated 1/15/19. This form stated, hoyer [lift] malfunctioned falling to floor. Pt [patient] hit on bridge of nose [with] crossbar . This form documented the lift turned over when transferring Resident #49 from bed to the wheelchair with wound treatment provided for the resident's skin tear. On 5/22/19 at 1:27 p.m., the licensed practical nurse (LPN #2) caring for Resident #49 was interviewed about the lift incident on 1/15/19. LPN #2 stated she was not working the day of the incident but was told there was something not working with the legs of the lift. LPN #2 stated the lift was taken out of service and checked out by maintenance after Resident #49's incident on 1/15/19. On 5/22/19 at 1:56 p.m., the unit manager (LPN #4) was interviewed about Resident #49's lift incident. LPN #4 stated she thought there was something mechanically wrong with the lift. LPN #4 stated the legs on the lift would not stay in place and when they lifted Resident #49, the entire lift turned over, hitting the resident in the nose. LPN #4 stated the staff members thought the lift was locked but the lock was not fully engaged. On 5/22/19 at 3:10 p.m., the DON was interviewed about Resident #49's lift incident of 1/15/19. The DON stated the certified nurses' aides (CNA's) thought the lift legs were locked but the lever was not fully in place. The DON stated maintenance checked the lift immediately after the incident and found nothing wrong with the lift. The DON stated the aides did not properly engage the leg locks prior to lifting Resident #49. The DON stated the legs shifted during the transfer causing the lift to turn over on its side. On 5/22/19 at 3:15 p.m., CNA #2 that was assisting Resident #49 at the time of the incident was interviewed. CNA #2 stated she and two other CNA's were assisting with the transfer. CNA #2 stated when they got the resident off the bed, the legs on the lift were open all the way. CNA #2 stated when they pushed the lift to get the resident over the chair, the legs went in and the lift tilted over. CNA #2 stated the resident was over the chair and went into the wheelchair when the lift tilted over. CNA #2 stated that the hanging bar on the lift hit the resident in the nose causing a skin tear. CNA #2 stated she did not ensure the locking lever on the lift was fully engaged prior to the transfer. On 5/23/19 at 7:45 a.m., the administrator was interviewed about Resident #49's lift incident. The administrator stated there was nothing found wrong with the lift immediately after the incident. The administrator stated, We think [CNA #2] did not fully engage the brake lever. The administrator stated the maintenance department performed safety checks on all mechanical lifts each month and an outside contractor performed checks on lifts once per quarter. Maintenance records prior to 1/15/19 documented the lift in use with Resident #49 had outside vendor testing last performed on 12/3/18 with a Passed status listed. The last facility check of the lift prior to the incident was documented on 12/30/18. This check indicated the lift did not open and close easily and documented, Control valve was loose and legs would not engage. tightened valve Removed Hair build up from wheels and cleaned lift No issues were found After Repair . (Sic) The facility's procedure titled Mechanical Lift (Sling Lift) (revised 11/28/17) documented in instructions for lift preparation was, Spread the legs of the lift locking them in the widest/maximum open position . The lift manufacturer's operating manual provided by the facility included on page 11 in instructions for lifting the patient, When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE lifting the patient .Adjustments for safety and comfort should be made before moving the patient . Page 23 of this manual documented under instructions for lifting the patient, .With the legs of the base open and locked, use the steering handle to push the patient lift into position . This finding was reviewed with the administrator and director of nursing during a meeting on 5/22/19 at 4:35 p.m. and on 5/23/19 at 9:10 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and clinical record review, the facility staff failed to perform a social service assessment and develop care interventions regarding grief/emotional support for one of 24 residents in the survey sample. Resident #15, with a recent death of a family member, had no assessment by social services to determine emotional care needs and grief support following the death. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, atrial fibrillation, hypothyroidism, major depressive disorder, anxiety, restless leg syndrome, high blood pressure and macular degeneration. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitive intact and feeling down, depressed and/or hopeless on most days. On [DATE] at 12:09 p.m., Resident #15 was interviewed about quality of life and care in the facility. Resident #15 stated she was frequently sad and was still upset about the recent death of her son. Resident #15 stated she did not talk and socialize with other residents in the facility and preferred to be alone. Resident #15 stated she recently had an increase in stomach aches and did not sleep well. Resident #15's clinical record documented a nursing note dated [DATE] stating, .Resident was notified of son passing this AM, resident visited son before passing and was aware of his condition. Daughter came to visit after being notified to visit with mom. The clinical record documented no assessment of the resident in response to her son's death. There were no further nursing or social worker notes indicating any assessment, identification of any emotional care needs or follow up with the resident regarding the death. Resident #15's plan of care (revised [DATE]) included no problems, goals and/or interventions regarding the resident's grief and/or emotional needs related to death of her family member. The plan of care made no mention of the family member's recent death. On [DATE] at 3:36 p.m., the facility's social worker was interviewed about Resident #15's grief and potential emotional needs related to the family member's death. The social worker stated the resident's son died maybe 6 to 8 weeks ago. The social worker stated she had talked with Resident #15 since the son's death but did not remember how many times. The social worker stated she did not document anything about her visits in the clinical record. When asked about a plan of care regarding the resident's grief process and any identified emotional needs, the social worker stated, Anybody could add care plan items. The social worker stated she had added nothing to the care plan about Resident #15's grief or emotional needs regarding the son's death. When asked how the facility staff knew what type of emotional support the resident needed without an assessment, the social worker stated she visited residents all the time but did not document anything in clinical records. The social worker stated the resident had a strained relationship with the son prior to his death. The social worker stated Resident #15 was doing better but had experienced a recent decline, needing more assistance. The social worker stated she did not know anything about a plan of care regarding emotional support for the resident. On [DATE] at 4:00 p.m., the registered nurse (RN #2) responsible for MDS and care plans was interviewed. RN #2 stated the social worker was responsible for care plan items related to mood, behaviors and emotional health. RN #2 stated there was no plan of care developed regarding Resident #15's grief or emotional needs related to the death. These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 4:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review the facility staff failed to ensure medications were properly labeled on one of three medication carts: B-wing front hall. A vial of insulin was opened without an open date and available for administration. Findings include: On [DATE] at 4:30 p.m. the medication cart on B-wing was inspected with RN (registered nurse) # 1. An opened vial of insulin (Humalog) was observed in the medication cart. There was a label on the bottle which documented Discard 28 days after opening. The vial did not have a date indicating when it had been opened. RN # 1 stated Oh, you're right; there's no date . RN # 1 then picked up the vial and stated I'll fix that right now and began to write the current day's date on the vial. This surveyor stopped her asking how she could be sure when the vial was actually opened, and if it had already expired? RN # 1 then stated You have a point; I guess we should take it [to the med room] so we can get a new one. The DON (director of nursing) was asked for a policy on labeling and storage of medications and biologicals [DATE] at 4:40 p.m. The policy was received [DATE] at 8:00 a.m. The policy Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles documented 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. The attached table to the policy for insulin included that type of insulin (Humalog) and directed Opened and stored at room temperature 28 days from opening. The administrator and DON were informed of the above findings during a meeting with facility staff [DATE] beginning at 4:05 p.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to implement interventions to maintain bowel and bladder continence for one of 24 residents in the survey sample. Resident #11 had no interventions implemented for over 3 months in response to an assessed decline in bowel and bladder continence. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included anxiety, disc degeneration, Alzheimer's dementia, cataracts, cerebrovascular disease, osteoarthritis, history of breast cancer, dementia with behaviors, depression and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented a decline in bowel and bladder function starting in February 2019. MDS assessments dated 10/2/18 and 12/26/18 documented Resident #11 was always continent of bowel and bladder function. A bowel and bladder evaluation tool dated 1/10/19 documented Resident #11 had independent mobility, moderately impaired cognitive skills and listed the resident as Mostly continent of bowel and bladder function. This evaluation documented the resident was a good candidate for a retraining program and rarely had episodes of incontinence unless she was acutely ill and weak. Resident #11's quarterly MDS dated [DATE] documented a decline in bowel and bladder continence. Section H. of this MDS listed the resident was frequently incontinent of bowel (2 or more episodes of incontinence but at least one continent bowel movement in 7 day look back period) and occasionally incontinent of bladder (less than 7 episodes of incontinence). Resident #11's plan of care (revised 3/7/19) included no problems, goals and/or interventions regarding a decline in bowel and bladder continence. The care plan listed the resident required assistance for activities of daily living, including toileting but included no mention of the resident's assessed frequent bowel incontinence and occasional bladder incontinence. Another bowel and bladder evaluation was completed on 4/10/19 listing the resident's health as stable with independent mobility and documented the resident as a good candidate for a retraining program. There was no evidence of analysis of the resident's bowel/bladder habits or any interventions implemented to assist the resident to maintain continence and/or reduce her episodes of bowel and bladder incontinence. On 5/22/19 at 10:10 a.m., the certified nurse's aide (CNA #1) routinely caring for Resident #11 was interviewed about the resident's bowel/bladder function. CNA #1 stated Resident #11 was mostly incontinent during the night. CNA #1 stated the resident frequently did not wake up to go to the restroom at night. CNA #1 stated the resident ambulated on her own during the day and was mostly continent when awake. CNA #1 was not aware of a scheduled toileting plan for Resident #11 or any other interventions regarding the resident's toileting habits. On 5/22/19 at 10:25 a.m., a licensed practical nurse (LPN #1) working on Resident #11's unit was interviewed about bowel/bladder assessments. LPN #1 stated if residents with incontinence were assessed as good candidates for retraining, they usually initiated a tracking tool to monitor the resident's bowel/bladder habits. LPN #1 stated the tracking tool helped them to develop a scheduled toileting plan or interventions to assist the resident to maintain continence. LPN #1 stated she was not aware of anyone on the unit with tracking or scheduled toileting plan. LPN #1 presented a blank copy of the bowel/bladder tracking form. This form titled Bowel and Bladder Pattern Record (undated) documented, Bowel and bladder pattern monitoring will be done on admission and any significant changes in Bowel and Bladder Pattern. On 5/22/19 at 1:40 p.m., LPN #2 that cared for Resident #11 was interviewed about the bowel/bladder decline. LPN #2 stated the resident usually went to the bathroom on her own and did not frequently ask for assistance. LPN #2 was not aware of any interventions regarding the assessed decline in continence and stated the resident was not on any type of scheduled toileting program. LPN #2 stated they used to have a tracking form but did not know if that was still used after going to computerized records. On 5/22/19 at 1:50 p.m., the unit manager (LPN #4) was interviewed about any plan of care regarding Resident #11's decline in bowel/bladder function. LPN #4 stated nothing had been initiated for Resident #11 regarding a toileting plan or program. On 5/22/19 at 2:06 p.m., the director of nursing (DON) was interviewed about Resident #11. The DON stated Resident #11 had increasing behaviors and progressive dementia. The DON stated she did not know of any interventions implemented in response to the resident's assessed decline in continence. On 5/22/19 at 2:45 p.m., the registered nurse (RN #2) responsible for MDS and care plans was interviewed about Resident #11. RN #2 stated there had been no plan of care developed regarding incontinence for Resident #11. RN #2 stated the resident's last care plan meeting/review was 3/7/19 and staff members brought up nothing regarding the bowel/bladder decline. RN #2 stated care plans were developed based upon MDS assessments, morning staff meetings and resident care plan meetings. This finding was reviewed with the administrator and director of nursing during a meeting on 5/22/19 at 4:05 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure one of 24 residents was free from unnecessary medications. Resident #11 had an as needed order for the anti-anxiety medication lorazepam (Ativan) renewed and in place beyond 14 days without a clinical justification and physician specified duration. Resident #11 was administered 37 doses of the as needed lorazepam from [DATE] through [DATE] without documented assessments indicating the need for the medicine or prior attempts at non-pharmaceutical interventions. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included anxiety, disc degeneration, Alzheimer's dementia, cataracts, cerebrovascular disease, osteoarthritis, history of breast cancer, dementia with behaviors, depression and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills and having wandering behaviors daily. Resident #11's clinical record documented a physician's order dated [DATE] for lorazepam 0.5 mg (milligrams) every 8 hours as needed for extreme anxiety or agitation for 90 days. Resident #11's medication administration records documented 37 doses of the as needed lorazepam were given from [DATE] through [DATE]. Doses were administered on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] (2 doses), [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE] (2 doses), [DATE], [DATE], [DATE] through [DATE] and [DATE]. There were no assessments and or reasons documented for the administration of the as needed lorazepam for thirty of the 37 doses. The seven notes documented the resident's behaviors as crying, tearful, itching, nausea and wandering/pacing. The nursing notes documented the following assessments/reasons for the as needed lorazepam. [DATE] - tearful, sister in facility and is taking her out for ride . [DATE] - noted pacing back and forth from a wing to b wing [DATE] - anxiety/nausea/vomiting [DATE] - itching and noted with increased agitation secondary to feeling funny . [DATE] - tearful [DATE] - teary on and off [DATE] - crying Resident #11's behavior tracking sheets from [DATE] through [DATE] were reviewed. The sheets documented behaviors demonstrated by the resident each shift. The only behaviors documented from [DATE] through [DATE] were nine instances of wandering and/or exit seeking behavior. All other shifts documented no behaviors demonstrated by the resident. A physician's progress note dated [DATE] documented an assessment regarding behaviors. The note documented, .seen today to follow-up on her behavior. I saw her [DATE] at which time we noted that over the past several months the patient had multiple changes in medications due to episodes of agitation, increased anxiety, obsessive behaviors, and at times somnolence. The patient's cognitive function is limited by her dementia but certainly affected by her medications .I was asked to review .medications today and speak with her family. They were particularly concerned about some angry outbursts that she had been having. The patient recently had risperidone added to her regimen. She remain on Ability, Wellbutrin, scheduled lorazepam at bedtime, Cymbalta, Namenda, and buspirone .Overall, the patient has done better .She did have an episode last evening of exit seeking but was able to be redirected . This physician note documented, .We will defer any major medication changes to psychiatry. The patient's as needed order for lorazepam that I had given has now expired. We will go ahead and reorder this at a dose of 0.5 mg every 8 hours as needed for extreme agitation/anxiety . Resident #11's plan of care (revised [DATE]) documented the resident had anxiety demonstrated by agitation, obsessive behaviors and exit seeking at times. The care plan listed the resident was an elopement risk due to poor cognition, dementia and adverse effects of medications. Interventions to reduce anxiety and prevent elopement included, anti-anxiety medication as ordered, allow time for resident to talk about her feelings, offer emotional support, have resident call and talk with sister anytime she was upset, offer diversional activities such as snacks, walks, talks, distract resident from wandering and Wanderguard applied to wrist to prevent unsupervised exits. On [DATE] at 1:00 p.m., the licensed practical nurse unit manager (LPN 4) was interviewed about assessments or clinical reasons for administration of as needed Lorazepam to Resident #11. LPN #4 stated she was not sure but knew that the family was particular about her medications. LPN #4 stated she would check and advise of why the as needed doses were administered. On [DATE] at 1:11 p.m., the director of nursing (DON) was interviewed about Resident #11's as needed lorazepam. The DON stated the pharmacist told her that it would meet regulation if the as needed order had a stop date. The DON stated the physician re-ordered the as needed Lorazepam on [DATE] and she requested the 90-day limit based upon the advice from the consultant pharmacist. On [DATE] at 2:30 p.m., LPN #2 who routinely cared for Resident #11 was interviewed about the as needed lorazepam administration. LPN #2 stated the resident at times was inconsolable and exit seeking. LPN #2 stated, When we give her [Resident #11] Ativan, she really calms down, is easier to redirect. When asked about any non-drug interventions, LPN #2 stated talking with her sister helped along with re-direction or activities. LPN #2 stated that sometimes the interventions helped but not always. LPN #2 stated when she gave the as needed lorazepam, the resident was usually emotional. LPN #2 stated there was another nurse on the unit that administered the lorazepam to Resident #11 a lot but that nurse no longer worked at the facility. When asked about documented assessments regarding the need for the lorazepam or any non-drug interventions attempted, LPN #2 stated she was not always good about documenting. LPN #2 stated most of the doses she administered were because the resident was not consolable. On [DATE] at 7:35 a.m., the DON was interviewed again about Resident #11 and the lack of documented assessments reflecting extreme agitation/anxiety as required in the physician's order or attempted non-drug interventions prior to giving the medication. The DON stated the nurses did not always make a note about why the as needed lorazepam was given. When asked if wandering and exit seeking was considered an extreme behavior and justification for the lorazepam, the DON stated, I'm not sure that is a reason for Lorazepam. The Nursing 2017 Drug Handbook on pages 902 and 903 describes lorazepam (Ativan) as an anxiolytic benzodiazepine used for the treatment of anxiety and insomnia from anxiety and/or stress. This reference lists drowsiness, sedation, unsteadiness and disorientation as possible adverse reactions to the medication. Precautions with use of lorazepam included, Use cautiously in elderly, acutely ill or debilitated patients . (1) These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 4:35 p.m. (1) [NAME], [NAME], [NAME] and [NAME]. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.