Based on staff interview and clinical record review the facility staff failed to correctly code a minimum data set (MDS) assessment for 1 of 3 closed record reviews, Resident #86. The findings included: For Resident #86, the facility staff coded the MDS as acute hospitalization when the resident discharged home. Resident #86's face sheet listed diagnoses which included but not limited to hypertension, heart failure, dementia, and anxiety. Section A (Identification Information), subsection A2105 (discharge status) of Resident #86's discharge assessment coded the resident as being discharged to Short-Term General Hospital (acute hospital). This MDS has an assessment reference date of 04/12/24 and listed the discharge as unplanned. Resident #86's clinical record was reviewed and contained a nurse's progress note dated 04/12/24 which read in part, Res (resident) daughter arrived at facility and was upset about a bill they owed the facility. Stated she was taking her mom home and that she was not paying this bill. Res was educated on the importance of not leaving the facility AMA (against medical advice). Res and daughter verbalized understanding. Res signed AMA and daughter exited the facility with res and all res. belongings. Dr. (name omitted) aware of situation. Surveyor spoke with the MDS coordinator on 06/27.24 at 9:15 am regarding Resident #86's discharge status. Surveyor asked MDS coordinator if resident was hospitalized , and MDS coordinator stated they were not. Surveyor then asked MDS coordinator if the MDS was coded correctly, and MDS coordinator stated that it was not, and they would fix it. The concern of not coding the resident's MDS correctly was discussed with the administrator, director of nursing, and regional nurse consultant on 06/27/24 at 1:40 pm. No further information provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 medication errors in 26 opportunities for a medication error rate of 7.69%. These medication errors affected Resident #20 and #82. The findings included: 1. For Resident #20, the facility staff failed to administer the probiotic, Lactobacillus Acidophilus as ordered by the medical provider. Resident #20's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Essential Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Constipation, and Chronic Kidney Disease Stage 3. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. On 6/26/24 at 8:57 AM, surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #20's morning medications. A reconciliation of the administered medications with the current provider orders revealed a current order for Lactobacillus Acidophilus one (1) capsule once daily for gut health at 9:00 AM. Surveyor did not observe LPN #2 administer Lactobacillus Acidophilus. Surveyor returned to LPN #2 at 10:10 AM and inquired about the Lactobacillus Acidophilus, LPN #2 stated they did not give the medication as it did not appear on the MAR (Medication Administration Record) screen for administration. LPN #2 stated some medications were not pulling to the MARs with the new system and the facility was having daily conference calls with the system provider. On 6/26/24 at 4:33 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of the facility medication error rate of 7.69% and Resident #20 not receiving medications as ordered. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/24. 2. For Resident #82, the facility staff failed to administer a Lidocaine 5% medicated patch to the resident's leg as ordered by the medical provider. Resident #82's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Hemiplegia and Hemiparesis, Peripheral Vascular Disease, and Alzheimer's Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/26/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. On 6/26/24 at 9:07 AM, surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #82's morning medications. A reconciliation of the administered medications with the current provider orders revealed a current order for Lidocaine 5% medicated patches to be applied to the leg and lower back once a day at 9:00 AM. Surveyor observed LPN #2 apply a Lidocaine patch to Resident #82's lower back only. Surveyor returned to LPN #2 at 10:12 AM and inquired about the order for a Lidocaine patch to the resident's leg. LPN #2 stated Resident #82 had been refusing the patch to their leg, but LPN #2 acknowledged they did not ask the resident if they wanted the Lidocaine patch applied today. On 6/26/24 at 4:33 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of the facility medication error rate of 7.69% and Resident #82 not being offered a Lidocaine patch to their leg as ordered. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/24.

Based on observation, staff interview, and facility document review, the facility staff failed to store all drugs and biologicals in locked compartments on 1 of 2 nursing units, Unit 1. The findings included: For Unit 1, the facility staff failed to lock an unattended medication cart. On 6/26/24 at 8:46 AM, during a medication pass and pour observation, Licensed Practical Nurse (LPN) #1 prepared medications for a resident, entered the resident's room and administered the medications while leaving the medication cart in the hall, unlocked, unattended, and out of direct sight. When LPN #1 returned to the medication cart, they acknowledged the cart was left unlocked. Surveyor requested and received the facility policy titled General Dose Preparation and Medication Administration with a revision date of 4/30/24 which read in part, .7. Facility should ensure that medication carts are always locked when out of sight or unattended . On 6/26/24 at 4:33 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of LPN #1 leaving a medication cart unlocked and unattended. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/24.

Based on staff interview and facility document review, the facility staff failed to implement the COVID-19 vaccination process in the attempt to prevent the transmission of COVID-19 for 2 of 93 employees. The staff vaccination rate was 97.8%. The findings included: The facility policy titled, Employee COVID-19 Vaccination Policy with a revision date of 01/27/22 read in part, The goal of the facility is to safeguard the health of our employees and their families; our residents and visitors; and the Facility at large from COVID-19. All employees are required to receive a FDA authorized and/or approved COVID-19 vaccination as required by the Interim Final Rule of the Centers for Medicare Services (CMS) regarding healthcare staff COVID-19 vaccination, unless a reasonable accommodation from this requirement due to disability, medical condition, or sincerely held religious belief, practice or observance requested and approved . The facilities contingency plan for unvaccinated staff read in part, Employee vaccination rate is not at 100% compliance at this time. Our goal is to be 100% by 3/27/2022 unless the employee has received an exemption .we will continue to educate/encourage unvaccinated staff members to try to take the vaccine and that they understand that they will not have employment at this facility if they do not comply with the mandate. On 02/01/22, the facility provided a copy of their COVID-19 Staff Vaccination Status for Providers matrix. Employee #1 and employee #2 were marked as Not vaccinated without exemptions/delay. As of 02/03/22, the facility had no positive COVID-19 resident's in house and 3 current positive staff. These staff were currently not working at the facility. 1. Employee #1, was a therapy employee-hire date 06/05/2019. Employee #1 had requested a Religious Accommodation from COVID-19 Vaccination this exemption was denied. The facility provided paperwork to indicate the employee had requested this exemption on 11/15/21. The company denied the exemption on 11/16/21 as The accommodation would cause an undue hardship based on imposing a direct threat to the health and safety of the employee and those living and working in the workplace. On 02/03/22 at 9:56 a.m., employee #1 stated their exemption was denied as they were a direct threat. Employee #1 stated they worked directly with residents of the facility, generally worked with from 4 to 8 residents daily, and they did not attempt to appeal the exemption, as they did not know that was an option. Employee #1 stated the company seemed very resolute in their decision, they had been educated multiple times on the COVID-19 vaccine, they wore an N95 face mask and eye wear when working with the residents, and they were being tested twice a week by the facility for COVID-19. The facility provided a negative rapid test for this staff dated 02/03/22. On 02/03/22 at 2:40 p.m., the DON stated they would continue to provide education in regards to the COVID-19 vaccine and continue to schedule vaccine clinics. No further information regarding employee #1 and the COVID-19 vaccine was provided to the survey team prior to the exit conference. 2. Employee #2, was a PRN (as needed) therapy employee-hire date 04/08/2014. This employee tested positive for COVID-19 on 01/22/22 and was not currently working in the facility. On 02/03/22 at 10:51 a.m., the DON (director of nursing) stated employee #2 last worked with residents of the facility on 01/15/22, was at the facility to complete training on 01/20/22 and 01/22/22, tested positive for COVID-19 on 01/22/22 and had not worked since. The DON stated this staff person would have to be vaccinated before they were allowed back in the building. When asked if there was a reason this staff person was not vaccinated the DON stated they were not sure. On 02/03/22 at 11:03 a.m., director of rehab stated they did not know why staff #2 was not vaccinated. On 02/03/22 at 2:40 p.m., meeting with the DON and administrator, the DON stated employee #2 was eligible for the COVID-19 vaccine, they would continue to provide education in regards to the COVID-19 vaccine and continue to schedule vaccine clinics. No further information regarding employee #2 and the COVID-19 vaccine was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review facility staff failed to ensure food was stored under safe and sanitary conditions in one of one walk-in refrigerators and one of one dry storage rooms. The findings were: During the initial kitchen tour on 02/01/2022 at 2:03 p.m., accompanied by one of the facility's cooks, expired items were found within the walk-in refrigerator and dry storage room. One unopened box of individual sour cream packets had a printed expiration date of 11/19/2021, one unopened container of Ricotta cheese had a printed expiration date of 01/02/2022 In the dry storage room there were 2 (two), unopened, opaque, one-quart paper containers of honey thick lemon water with a printed expiration date of 01/27/2022. The cook stated that he/she must have missed those two containers when he/she checked for expired dates. The facility's dietary manager (DM) arrived on 02/01/2022 at approximately 2:45 p.m. as the initial tour was concluding. On 02/01/2022 at approximately 2:50 p.m. the DM acknowledged the sour cream was expired and threw the box away. The DM acknowledged the cook had reported the 2(two) one-quart containers of honey thick lemon water had expired. On 2/01/2022 at 4:05 p.m., when asked about the facility's process of observing for expiration dates on food/products, the DM stated the whole kitchen staff looked for expiration dates on food products. The DM reported typically the night cook went through the refrigerators and added that looking for expired products was everybody's responsibility. After the surveyor requested a policy on the facility's process for managing food expiration dates, on 02/02/2022 at 1:45 p.m., the DM provided 1 (one) untitled piece of paper with typed information describing the process for receiving food products. The document did not identify the facility or corporation or where it originated. The document read in part, Dating/Labeling/Rotating: Everything that is delivered is to be clearly marked with a marker with the received date. This is the only ways [sic] we can prove rotation. FIFO-first in first out. Everything is to re[sic] be rotated so the new is to the back and the older gets pulled to the front so it gets used first. When you open any item it is to have an Open [sic] date and a use by date. Example: I open pudding and put it in a half gallon container, I will put a O or opened 6/3 EXP or UB 6/5 . Both the administrator and director of nursing (DON) were notified of the above observations on 02/02/2022 at 4:45 p.m. during an end of day meeting with the survey team in the conference room. There was no further information provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility document review, the facility staff failed to notify the physician of changes in Resident condition for 2 of 24 Residents in the survey sample, Resident # 18 and Resident #76. The findings included: 1. The facility staff failed to notify the physician of low blood sugar level for Resident # 18. Resident # 18 was a [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, down syndrome, unspecified intellectual disabilities, type 1 diabetes mellitus, and hypertension. The clinical record for Resident # 18 was reviewed on 9/5/19 at 9:30 am. The most recent MDS (minimum data set) assessment for Resident # 18 was a quarterly assessment with an ARD (assessment reference date) of 6/12/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 18 had a BIMS (brief interview for mental status) score of 5 out of 15, which indicated that Resident # 18's cognitive status was severely impaired. The current plan of care for Resident # 18 was reviewed and revised on 6/7/19. The facility staff documented a focus area for Resident # 18 as, Resident has increased nutrition hydration risk related to: anemia, hyperlipidemia, GERD (gastroesophageal reflux disease), diabetes with ketoacidosis without coma, hyperkalemia, acute pancreatitis without necrosis or infection, weight loss, sig (significant) weight loss noted. Interventions included but were not limited to, Medicine kit for low blood sugars as ordered. Resident # 18 had current orders that included but were not limited to, Glucagon Emergency Kit 1 mg (milligram) Inject 1 application intramuscularly as needed for low blood < (less than) 50 may inject glucagon emergency kit if blood sugar <50 and resident is unable to take PO (by mouth) intake, which was initiated by the physician on 3/29/18. On 9/5/19 at 2:52 pm, the surveyor observed the following notes documented in the progress notes for Resident # 18. An eMAR (electronic medication administration record) medication administration note was documented on 9/1/19 at 12:30 am. The note was documented as, FSBS as needed for DM hypoglycemic, thrashing in bed blood sugar 47. An eMAR medication administration note was documented on 9/1/19 at 12:37 am. The note was documented as, Glucagon emergency kit 1 mg application intramuscularly as needed for low blood <50 may inject glucagon emergency kit if blood sugars <50 and resident is unable to take PO intake blood sugar 47. The surveyor reviewed the clinical record further for Resident # 18 and did not observe any documentation that reflected that the physician had been notified of Resident # 18 having a blood sugar of 47 on 9/1/19. On 9/6/19 at 2:35 pm, the regional vice president of operations, administrator, and director of nursing were made aware of the findings as stated above. The surveyor asked the director of nursing if she expected the nursing staff to notify the physician if a Resident had a low blood sugar that required the use of glucagon. The director of nursing informed the surveyor that she did not expect the nursing staff to notify the physician each time Resident # 18 had a low blood sugar reading because Resident # 18 had a history of having low blood sugars. The surveyor requested to see the facility diabetic care policy. On 9/6/19 at 4:40 pm, the facility staff provided the surveyor with a copy of the Care of the Diabetic Patient policy. The policy contained documentation that included but was not limited to, .Note: Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention. Hypoglycemia (blood sugar below reference ranges). Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: b) Restlessness and or muscle twitching j) (more severe) stupor, unconsciousness and or convulsions If these or other abnormal conditions exist, notify the physician. On 9/6/19 at 5:20 pm, the regional vice president of operations, director of nursing, and administrator were made aware of the findings as stated above. The survey team provided the opportunity for the administrative team to submit more documentation to dispute the deficient practice of not notifying the physician of Resident # 18's low blood sugar of 47 on 9/1/19. The administrative team reported that they had no further information regarding this issue to submit to the survey team. 2. The facility staff failed to notify the physician when Resident #76 repeatedly refused to have weight obtained as ordered by the physician. Resident #76 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, dementia, anxiety disorder and depression. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/22/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. During the clinical record review on 9/5/19, the surveyor noted the physician had ordered for Resident #76 to obtain a daily weight. Resident refused to have weights obtained on the following dates: 8/14/19, 8/18/19, 8/19/19, 8/21/19, 8/22/19 and 8/23/19. The resident had been readmitted to the facility on [DATE] with the diagnosis of Congested Heart Failure following a hospital stay on 8/1/19. On 9/6/19 at 10:30 am, the surveyor notified the ADON (Assistant Director of Nursing) of the above documented findings. The surveyor asked the ADON if the physician had been notified of the resident refusing daily weights. ADON stated, No he wasn't. The surveyor asked if this was something that need to be reported to the physician due to the resident having a hospitalization for congested heart failure. The ADON stated, Yes, I expect the staff to notify the physician of the resident refusing daily weights due to the resident returning back to the facility on 8/8/19 with the diagnosis of congest heart failure. The surveyor notified the administrative team of the above documented findings on 9/6/19 at approximately 3:30 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 9/6/19.

Based on observation, staff interview, Resident interview, family interview, and clinical record review the facility staff failed to review and revise a CCP (comprehensive care plan) for 1 of 24 Residents, Resident #28. The findings included: For Resident #28 the facility staff failed to revise the care plan for Resident has increased nutrition/hydration risk . Resident #28's face sheet listed an admission date of 09/26/17 and a readmission date of 06/21/19. The Resident's diagnosis list indicated diagnoses, which included, but not limited to protein-calorie malnutrition, anxiety, atrial fibrillation, osteoarthritis, dysphagia, hypothyroidism, Vitamin B12 deficiency, edema, osteoporosis, anemia, dementia, adult failure to thrive, depression, insomnia, anorexia, pseudobulbar affect, diabetes mellitus, benign prostatic hyperplasia, congestive heart failure and peripheral vascular disease. Resident #28's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/28/19 assigned the Resident a BIMS (brief interview for mental status) score of 8 out of 15 in section C, cognitive patterns. Section G, functional status, coded the Resident as needing extensive help of one-person physical assist in the area of eating. Resident #28's CCP was reviewed and contained a care plan for Resident has increased nutrition/hydration risk . Interventions for this care plan included Feed Resident all meals x1 assist. This intervention was initiated on 07/22/19. The physician's orders section of the Resident's clinical record was reviewed and contained a physician's order summary, which read in part Eating with assist x 1 assist with feeding. This order was discontinued on 07/19/19. Surveyor spoke with Resident's daughter on 09/06/19 at approximately 8:25 am. Resident's daughter stated during Resident last hospitalization the physician recommended the Resident have feeding assistance. The Resident's daughter stated that she did not think this was being done. Surveyor spoke with CNA (certified nurse's aide) #2 on 09/06/19 at approximately 8:45 am regarding Resident #28's feeding assistance. CNA #2 stated that Resident feeds himself and the she will ask him if he wants/needs help when she goes back to pick up his tray. Surveyor spoke with DON (director of nursing) on 09/06/19 at approximately 10:10 am regarding Resident #28. DON stated that Resident feeds himself and staff will offer to assist him if he does not eat. DON also stated that Resident does not like to be fed. Surveyor spoke with the MDS coordinator on 09/06/19 at approximately 2:25 pm regarding Resident #28. MDS coordinator stated that Resident has an order for feeding assistance. Surveyor showed MDS coordinator the Resident #28's order to feeding assistance and MDS coordinator stated, We should have taken it off the care plan. The concern of not reviewing/revising the Resident's CCP was discussed with the administrative team (administrator, DON, regional vice-president of operations) during a meeting on 09/06/19 at approximately 2:35 pm. No further information was provided prior to exit.

Based on observation, staff interview, Resident interview, family interview, clinical record review and facility document review the facility staff failed to provide ADL (activities of daily living) care for 1 of 24 Residents, Resident #28. The findings included: For Resident #28 the facility staff failed to provide nail care. Resident #28's face sheet listed an admission date of 09/26/17 and a readmission date of 06/21/19. The Resident's diagnosis list indicated diagnoses, which included, but not limited to protein-calorie malnutrition, anxiety, atrial fibrillation, osteoarthritis, dysphagia, hypothyroidism, Vitamin B12 deficiency, edema, osteoporosis, anemia, dementia, adult failure to thrive, depression, insomnia, anorexia, pseudobulbar affect, diabetes mellitus, benign prostatic hyperplasia, congestive heart failure and peripheral vascular disease. Resident #28's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/28/19 assigned the Resident a BIMS (brief interview for mental status) score of 8 out of 15 in section C, cognitive patterns. Section G, functional status, coded the Resident as needing extensive help of two person physical assist, in the area of personal hygiene. Resident #28's comprehensive care plan contained a care plan for self-care deficit. Interventions for this care plan include assist with oral care, nail care as needed. Surveyor observed Resident #28 on 09/05/19 at approximately 8:45 am. Surveyor observed Resident's fingernails to be long and somewhat jagged. Surveyor asked Resident #28 if staff cut his nails for him and he stated that they did not and that he gets his daughter to do it when she visits. Surveyor asked Resident if his nails being long bothered him and he stated that it did. Surveyor spoke with the DON (director of nursing) on 09/05/19 at approximately 11:30 am regarding nail care for Residents. DON stated that nail care is to be done during Residents bath or as needed. Surveyor asked the DON if nail care is documented when done, and she stated that it is not. Surveyor spoke with CNA (certified nurse's aide) #1 on 09/05/19 at approximately 11:45 am regarding nail care for Residents. Surveyor asked CNA #1 when nail care was done and CNA #1 stated we check them every day or so. CNA #1 also stated that Residents nails are cleaned/trimmed if needed when they are checked. Surveyor spoke with Resident's daughter on 09/06/19 at approximately 8:25 am. Surveyor asked Resident's daughter if the facility staff provided nail care for the Resident and she stated that they did not. The surveyor requested and was provided with a policy entitled Nail Care which read in part, Nursing staff will administer nail care in order to provide cleanliness and prevent infection. The concern of the facility staff not providing nail care for Resident #28 was discussed with the administrative team (administrator, DON, regional vice-president of operations) during a meeting on 09/05/19 at approximately 4:10 pm. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure that a resident with pressure ulcers receives necessary treatment and services by monitoring an area to the right heel as ordered by the physician for 1 of 24 residents (Resident # 81). The findings included: Resident # 81 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, hypertension, gout, paraplegia, and stage 4 sacral pressure ulcer. The clinical record for Resident # 81 was reviewed on 9/5/19 at 1:48 pm. The most recent MDS (minimum data set) assessment for Resident # 81 was a 14-day scheduled assessment with an ARD (assessment reference date) of 8/27/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 81 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 81 was cognitively intact. Section M of the MDS assesses skin conditions. In Section M0210, the facility staff documented that Resident # 81 had one or more unhealed pressure ulcers or injuries during the look back period for the 8/27/19 ARD. The current plan of care for Resident # 81 was reviewed and revised on 8/27/19. The facility staff documented a focus area for Resident # 81 as, At risk for skin breakdown related to: decreased mobility, weakness, incontinence, PVD (peripheral vascular disease), pressure ulcer on buttocks. Interventions included but were not limited to, Monitor affected area on right heel as ordered. Resident # 81 had orders that included but were not limited to, Monitor affected area on right heel, which was initiated by the physician on 8/26/19. On 9/5/19 at 4:11 pm, the regional vice president of operations, the facility administrator, and director of nursing was informed that the surveyor would like to observe Resident # 81's wounds during dressing changes on 9/6/19. On 9/6/19 at 10:50 am, LPN supervisor # 1 (licensed practical nurse) informed the surveyor that she was preparing to do dressing changes for Resident # 81. The surveyor informed LPN supervisor # 1 that she specifically wanted to observe that area to Resident # 81's right heel. LPN supervisor # 1 stated, He doesn't have an area on his heel. On 9/6/19 at 11:10 am, two surveyors was in the room with Resident # 81. Resident # 81 gave the surveyors permission to observe his right heel. Two surveyors observed small a dark red area to Resident # 81's right heel. On 9/6/19 at 1:55 pm, the surveyor interviewed LPN # 2. The surveyor asked LPN # 2 if the facility staff was providing treatment or monitoring any areas to Resident # 81's right heel. LPN # 2 stated, We are just taking care of his bottom, nothing on his foot. The surveyor and LPN # 2 reviewed the physician's orders for Resident # 81. LPN # 2 confirmed that Resident # 81 had orders to monitor affected area on right heel. The surveyor asked LPN # 2 if the facility staff had documented anything in Resident # 81's clinical record that supported that the facility staff was monitoring the affected area to Resident # 81's right heel as ordered by the physician. LPN # 2 and RN # 1 (registered nurse) reviewed Resident # 81's clinical record in the presence of the surveyor. RN # 1 stated, There is nothing documented that we are monitoring it. On 9/6/19 at 2:05 pm, the surveyor and LPN supervisor # 1 observed Resident # 81's right heel. The surveyor and LPN supervisor # 1 observed the small dark red area on Resident # 81's heel. The surveyor asked LPN supervisor # 1 to assess Resident # 81's right heel to determine if the heel was boggy. The surveyor observed LPN supervisor # 1 press on Resident # 81's heel. LPN supervisor # 1 stated, Yes it is boggy. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/14/19 at 11:55 am. The skin/wound note contained documentation that included but was not limited to, .Blistered stage 2 noted to right heel measured a 4x4, foam tx (treatment) ordered. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/26/19 at 3:26 pm, The skin/wound note contained documentation that included but was not limited to, .Monitor affected area to right heel. On 9/6/19 at 2:35 pm, the regional vice president of operations, administrator, and director of nursing were made aware that Resident # 81 had a blistered stage 2 documented in the clinical record and physician's orders to monitor area to right heel, and that LPN supervisor # 1 and LPN # 2 were not aware that Resident # 81 had an affected area to right heel or physician's orders to monitor the right heel. The administrative team was also made aware that the facility staff reviewed the clinical record along with the surveyor and did not observe documentation that supported that the area to Resident # 81's right heel was being monitored as ordered by the physician. On 9/6/19 at 5:20 pm, the surveyor provided the administrative team the opportunity to ask questions and present additional information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to provide treatment consistent with the comprehensive care plan related to IV therapy for 1 of 24 Residents in the survey sample, Resident # 284. The findings included: The facility staff failed to ensure that Resident # 284 had PICC (peripherally inserted central catheter) line flush and dressing change orders. Resident # 284 was an [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, abscess of right lower limb, hypertension, anxiety, and anemia. The clinical record for Resident # 284 was reviewed on 9/5/19 at 9:41 am. There was not a completed MDS (minimum data set) assessment for Resident # 284 during the time of the survey. The current plan of care for Resident # 284 was reviewed and revised on 9/3/19. The facility staff documented a focus area for Resident # 284 as, Resident is at risk for infection R/T (related to) PICC line, wound. Interventions included but were not limited to, Flush line as ordered, and IV procedures & site care per facility policies. Resident # 284 had orders that included but were not limited to, Ceftriaxone Sodium Solution Reconstituted 2 GM (gram) Use 2 gram intravenously one time a day for wound infection until 09/10/19 23:59 (11:59 pm) Q (every) 24 hours, which was initiated by the physician on 8/30/19. The surveyor reviewed all physician's orders for Resident # 284 and did not locate any orders to flush the PICC line or any orders for PICC line dressing changes. On 9/6/19 at 11:53 am, the surveyor interviewed the director of nursing. The surveyor asked the director of nursing for the facility policy that pertained to flushing and care if PICC lines. The director of nursing stated, I don't think we have a policy for that, but we get an order and we flush before and after antibiotic therapy. On 9/6/19 at 1:50 pm, the surveyor was in Resident # 284's room conducting a Resident interview. Resident # 284 showed the surveyor a single lumen PICC line in her right upper arm. The dressing over the PICC line was dated 8/28/19. The surveyor asked Resident # 284 if the nursing staff flushed her PICC line. Resident # 284 stated, Yeah, they always come back and flush it. On 9/6/19 at 1:52 pm, the surveyor conducted an interview with LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 if the facility flushed Resident # 284's PICC line before and after IV (intravenous) antibiotic therapy. LPN # 2 stated, Yeah, we should have an order. LPN # 2 and the surveyor reviewed the current physician's orders for Resident # 284 along with the surveyor. LPN # 2 stated, I don't see an order, but normally we do have an order for flushes. The surveyor asked LPN # 2 if the facility staff normally changed dressings on Residents that have PICC lines. LPN # 2 stated, Yes, the treatment nurse does it once a week. The surveyor and LPN # 2 reviewed the physician's orders for Resident # 284 and LPN # 2 confirmed that Resident # 284 did not have current orders for PICC line dressing changes. On 9/6/19 at 2:35 pm, the surveyor informed the administrator, director of nursing, and regional vice president of operations of the findings as stated above. The surveyor asked the director of nursing if the facility pharmacy had provided the facility with a policy on PICC line maintenance and usage. The director of nursing stated that she would look into it. On 9/6/19 at 5:20 pm, the director of nursing informed the surveyor that she did not locate a pharmacy policy on PICC line maintenance and usage. The surveyor provided the administrative team the opportunity to ask questions and provide information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to ensure that residents who need respiratory care by maintaining oxygen equipment for 2 of 24 residents in the sample survey (Resident #38 and #24). The findings included: 1. The facility staff failed to store Resident #38's nebulizer mask in a plastic bag when not in use by the resident. Resident #38 was admitted to the facility on [DATE] with the following diagnoses, but not limited to anemia, heart failure, dementia, anxiety disorder, depression and chronic obstructive pulmonary disease. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/3/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #38 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and extensive assistance of 2 staff members for bathing. During initial tour of the facility on 9/4/19 at 11:15 am, this surveyor observed the nebulizer mask on lying on the table bedside of the bed. It was not in a plastic bag. On 9/5/19 at approximately 10 am, the surveyor observed the nebulizer mask lying on the bedside table. Again, the surveyor noted the nebulizer mask was not stored in a plastic bag. At 4:13 pm, the surveyor notified the administrative staff of the above documented findings. The surveyor asked the DON (director of nursing) how nebulizer masks were to be stored when not in use by the resident. The DON replied, It is supposed to be stored in a plastic bag when not in use. The surveyor asked for the facility's policy concerning storage of a nebulizer mask when not in use by the resident. DON stated, We don't have a policy on this but I would hold my staff to storing the nebulizer mask in a plastic bag when not in use by the resident. No further information was provided to the surveyor prior to the exit conference on 9/6/19. 2. The facility staff failed to maintain oxygen equipment for Resident #24. Resident #24 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, heart failure, chronic obstructive disease and anxiety disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/20/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #24 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene. During the initial tour on 9/4/19 at approximately 12:30 pm, the surveyor observed that the resident was receiving oxygen by nasal cannula. The surveyor also noted there was no date on the oxygen tubing or on the water bottle. On 9/5/19 at 11:00 am, the surveyor observed that the oxygen tubing and water bottle did not have a date on it. At 4:16 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked the DON (director of nursing) who changes the tubing and water bottle on the oxygen concentrator and how is this done. The DON stated, The night shift nurses are responsible for changing these out once a week. The staff will date the oxygen tubing and water bottle with the date they were changed. The surveyor asked the DON for a copy of the facility's policy on date and changing the water bottle and oxygen tubing. The DON stated, I don't think the policy states anything about this. The surveyor asked the DON what protocol she would use if she had found the above documented findings. The DON stated, They night shift is to change the oxygen tubing and water bottle once a week. They are supposed to date these items also. No further information was provided to the surveyor prior to the exit conference on 9/6/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility document review, it was determined that the physician failed to visit and assess skin conditions for 2 of 24 Residents in the survey sample, Resident # 79 and Resident # 81. The findings included 1. The physician or nurse practitioner failed to assess skin conditions that had been reported by nursing staff during follow up visits with Resident # 79. Resident # 79 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], and had a facility readmission date of 3/10/18. Diagnoses included but were not limited to, type 2 diabetes mellitus, dementia, polyneuropathy, and edema. The clinical record for Resident # 79 was reviewed on 9/4/19 at 12:15 pm. The most recent MDS (minimum data set) assessment for Resident # 79 was a significant change assessment with an ARD (assessment reference date) of 8/20/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 79 had a BIMS score (brief interview for mental status) of 7 out of 15, which indicated that Resident # 79's cognitive status was severely impaired. Section M of the MDS assesses skin conditions. In Section M1040, the facility staff documented that Resident # 79 had a diabetic foot ulcer during the look back period for the 8/20/19 ARD. The current plan of care for Resident # 79 was reviewed and revised on 8/23/19. The facility staff documented a focus area for Resident # 79 as, Risk for altered skin integrity due to change in mobility, diabetes, edema. Interventions included but were not limited to, Treatment to right heel wound as ordered. Apply a foam dressing. Change as ordered. Resident # 79 had orders that included but were not limited to, Cleanse right heel wound with cleanser of choice, apply foam dressing every day shift Mon, Wed, Fri (Monday, Wednesday, Friday) for skin care, which was initiated by the physician on 8/22/19. On 9/4/19 at 1:13 pm, the surveyor was in the room with LPN # 1 and LPN # 3 while treatment was being administered to Resident # 79's right heel. The surveyor observed a round dark purple area about the size of a fifty-cent piece on Resident # 79's right heel. The surveyor observed an open area at the center of the wound. The surveyor reviewed the progress notes for Resident # 79. The surveyor observed a Skin/Wound Note for Resident # 79 that was documented on 8/21/19 at 23:14 (11:14 pm). The skin/wound note was documented as, Resident noted to have a broken blister to her R (right) heel area cleansed, tegaderm applied and message left for tx (treatment) nurse to eval and tx. Heelz-up in place per orders. A skin/wound note was documented on 8/22/19 at 13:13 (1:13 pm). The skin/wound note contained documentation that included but was not limited to, . New DFU (diabetic foot ulcer) noted to right heel. Area is measured at 7x6 and is a serous fluid filled blister. Edge of blister is torn and a mod (moderate) amt (amount) of serous drainage is noted. On 9/4/19 at 2:35 pm, the surveyor spoke with the director of nursing regarding the area to Resident # 79's right heel. The surveyor informed the director of nursing of the observation of the dark purple area to Resident # 79's heel and the documentation that the facility staff made in Resident # 79's clinical record that the area on Resident # 70's heel was a diabetic foot ulcer. The director of nursing stated, That not an area that I am comfortable with. We have a certified wound care nurse, and I leave those things up to her to take care of. The surveyor requested to interview LPN # 1 and LPN # 3. On 9/4/19 at 3:05 pm, the surveyor interviewed LPN # 1 and LPN # 3 in presence of the director of nursing and the survey team. LPN # 1 stated that she was filling in for the certified wound care RN who was on vacation. The surveyor asked LPN # 1 what type of wound was on Resident # 79's right heel. LPN # 1 stated, An old calloused area that has healed. The surveyor informed LPN # 1 of her observation of the wound to Resident # 79's right heel, which was a dark purple area on the heel with an open area in the center of the wound. The surveyor asked LPN # 1 if she had observed the wound as the surveyor had described. LPN # 1 agreed that she had observed the wound as described by the surveyor. The surveyor stated that the wound observed on Resident # 79's right heel was in a bony area, which normally was caused by pressure. LPN #1 stated, I agree in the presence of the survey team. The surveyor asked the director of nursing what criteria the facility went by to determine that the area on Resident # 79's right heel was a diabetic ulcer instead of a pressure ulcer. The director of nursing stated she would look into it further and report back to the surveyor. On 9/4/19 at 3:35 pm, the director of nursing provided the surveyor with a journal article with a highlighted portion, which was documented as, Any pressure ulcer on the foot of a person with diabetes is a diabetic foot ulcer-as any traumatic wound, including a thermal or chemical injury. Vowden, P., Vowden K. (2015). Diabetic foot ulcer or pressure ulcer? That is the question. Diabetic Foot Journal 18: 62-66. The surveyor asked the director of nursing if this was the facility standard of practice for staging and classification of wounds. The director of nursing stated that this was the information that was utilized by the facility wound nurse who was certified in the area of wounds. The surveyor asked the director of nursing to provide the facility policy and standard of practice on wound staging and classification. On 9/5/19 at 8:42 am the director of nursing provided the surveyor with the facility Pressure Ulcer Policy and what the director of nursing identified as the facility standard of practice for staging wounds. The facility pressure ulcer policy contained documentation that included but was not limited to, .Assessment and Treatment of Pressure Ulcer(s): 3. Differentiate the type of ulcer (pressure-related versus non-pressure related. Pressure ulcers are usually located over a bony prominence such as sacrum, heel) 6. The facility will notify family/responsible parties and the physician of any newly acquired or worsening pressure ulcers and treatments. The facility standard of practice for Pressure Ulcer Staging contained documentation that included but was not limited to, .Stage II The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. The director of nursing also provided the surveyor with a progress note from the nurse practitioner dated 9/4/19. The progress note contained documentation that included but was not limited to, .R (right) heel has some erythema, no drainage to healing non-pressure diabetic ulcer with calloused upper edge. The surveyor asked the director of nursing had the nurse practitioner seen Resident # 79 to assess the area to the right heel prior to the surveyor bringing up a discrepancy in the classification of the wound. The director of nursing stated, No. The surveyor reviewed the physician progress notes for Resident # 79. The surveyor observed that the facility nurse practitioner had seen Resident # 79 on three occasions since the initial identification of the area on Resident # 79's right heel on 8/21/19. Upon review of the progress notes dated 8/26/19, 8/29/19, and 9/3/19, the surveyor did not observe any documentation that indicated that the facility nurse practitioner had assessed the area to Resident # 79's right heel. On 9/6/19 at 11:23 am, the surveyor interviewed the facility nurse practitioner. The surveyor asked the facility nurse practitioner had she assessed the area to Resident # 79's right heel prior to 9/4/19. The facility nurse practitioner stated that she had seen Resident # 79 on several occasions but did not assess the area to Resident # 79's right heel prior to 9/4/19. The facility nurse practitioner stated that she read the notes that had been documented on the area on Resident # 79's right heel and had worked closely with the facility's certified wound care nurse and trusted her judgement. On 9/6/19 at 2:35 pm, the administrator, director of nursing, and regional vice president of operations were made aware of the findings as stated above and of the issue that notification of a new area to Resident # 79's right heel was identified on 8/21/19 and treatment was started on 8/22/19. The facility nurse practitioner saw the resident on three occasions since the identification of the area to Resident # 79's right heel and did not assess the area until after the surveyor identified a discrepancy on 9/4/19. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19. 2. The physician or nurse practitioner failed to assess Resident # 81 following the identification of a stage 2 pressure ulcer to the right heel. Resident # 81 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, hypertension, gout, paraplegia, and stage 4 sacral pressure ulcer. The clinical record for Resident # 81 was reviewed on 9/5/19 at 1:48 pm. The most recent MDS (minimum data set) assessment for Resident # 81 was a 14-day scheduled assessment with an ARD (assessment reference date) of 8/27/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 81 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 81 was cognitively intact. Section M of the MDS assesses skin conditions. In Section M0210, the facility staff documented that Resident # 81 had one or more unhealed pressure ulcers or injuries during the look back period for the 8/27/19 ARD. The current plan of care for Resident # 81 was reviewed and revised on 8/27/19. The facility staff documented a focus area for Resident # 81 as, At risk for skin breakdown related to: decreased mobility, weakness, incontinence, PVD (peripheral vascular disease), pressure ulcer on buttocks. Interventions included but were not limited to, Monitor affected area on right heel as ordered. Resident # 81 had orders that included but were not limited to, Monitor affected area on right heel, which was initiated by the physician on 8/26/19. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/14/19 at 11:55 am. The skin/wound note contained documentation that included but was not limited to, .Blistered stage 2 noted to right heel measured a 4x4, foam tx (treatment) ordered. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/26/19 at 3:26 pm, The skin/wound note contained documentation that included but was not limited to, .Monitor affected area to right heel. The surveyor reviewed the physician progress notes for Resident # 81 and observed that Resident # 81 had been see by the physician on 8/22/19 and 8/29/19 and the physician did not document an assessment of the stage 2 area to Resident # 81's heel on either visit. On 9/6/19 at 2:35 pm, the regional vice president of operations, administrator, and director of nursing were made aware that physician did not assess the area to Resident # 81's right heel following the initial identification of the area on 8/14/19. The surveyor provided the administrative team the opportunity to ask questions and present additional information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure that 1 of 24 Residents in the survey sample were free of unnecessary psychotropic medications, Resident # 25. The facility staff failed to ensure that Resident # 25 had a prn (as needed) psychotropic medication ordered that was limited to 14 days. Resident # 25 was an [AGE] year-old- female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, dementia, anxiety, major depressive disorder, and anxiety. The clinical record for Resident # 25 was reviewed on 9/5/19 at 10:04 am. The most recent MDS (minimum data set) assessment for Resident # 25 was a quarterly assessment with an ARD (assessment reference date) of 6/20/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 25 had a BIMS (brief interview for mental status) score of 2 out of 15, which indicated that Resident # 25's cognitive status was severely impaired. The current plan of care for Resident # 25 was reviewed and revised on 4/2/19. The facility staff documented a focus area for Resident # 25 as, At risk for adverse effects R/T (related to) psychoactive medication use: anxiety, dementia with behaviors, psychosis, depression, antipsychotic. Interventions included but were not limited to, Reduction in medication doses when indicated. Resident # 25 had current orders that included but were not limited to, Ativan tablet 0.5 mg (milligram) Give 0.5 tablet by mouth as needed for agitation BID (two times daily), which was initiated by the physician on 5/2/19. The surveyor reviewed the entire clinical record for Resident # 25 and did not locate a documented rationale by the physician to indicate the need for prn Ativan to exceed 14 days. On 9/6/19 at 2:35 pm, the administrator, the director of nursing, and regional vice president of operations was made aware of the findings as stated above. The director of nursing stated that she would review the chart further to identify any documented rationale to justify the use of prn Ativan beyond 14 days. The facility policy on Psychotropic Medication Documentation and Review contained documentation that included but was not limited to, .Procedure c. Diagnosis for the reason psychotropic medication is being given will be documented in medical record. On 9/6/19 at 5:20 pm, the director of nursing informed the surveyor that she did not locate a documented rationale to support Resident # 25 having prn Ativan for greater than 14 days. The surveyor provided the administrative team the opportunity to ask additional questions or provide information to dispute the deficient practice as stated above. No further information was provided to the survey team prior to the exit conference on 9/6/19.