Based on record review, family interview and staff interview the facility failed to notify the residents responsible party of a room change prior to moving the resident. This was a random opportunity for discovery during the compliant survey. Resident Identifier: #60. Facility Census: 58. Findings Include: a) Resident #60 During an interview with Resident #60's responsible party on 02/10/25 at 12:03 PM during a telephone interview , she stated, The last time they moved him they did not tell me. They just came in and packed up all his stuff and moved him. A review of the medical record on 02/10/25 in the afternoon found no indication the residents responsible party was notified of his room move. An interview with the Director of Nursing (DON) on the afternoon of 02/13/25 confirmed there was no evidence the residents responsible party was notified of his room move. She stated The social worker said she must have clicked the wrong button.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure all allegations of abuse and/or neglect was thoroughly investigated. This was true for Resident #59 and was a random opportunity of discovery during a complaint survey. This was determined to be past non-compliance because the facility had identified the failure and implemented an effective plan of correction to correct the non- compliance prior to the first day of the complaint survey. Resident Identifier: #59. Facility Census: 58. Findings Include: a) Resident #59 A review of the facility's reportable incidents on 02/10/25 found a reportable incident dated 02/15/24 pertaining to Resident #59. A review of the report found the following under the brief description of the incident: It is reported this afternoon (02/15/24) by (name of another state agency) worker that this resident allegedly received bruises and had multiple pressure ulcers of various stages upon returning home from (Name of facility). A review of the five day follow - up submitted by the facility on 02/19/24, found under the section titled, Corrective action by the facility the following, Investigation Completed- Allegations unsubstantiated Resident No longer in the facility. Also contained in the reportable investigation was document titled Complaint Investigation related to Resident #59. This was signed by the former Nursing Home Administrator (NHA) and read as follows, On 02/15/24, (Name of local state agency) worker, (First and Last name of the state agency worker) was in the facility for a care plan meeting for one of the residents. Following the care plan meeting, she informed the DON (Director of Nursing) that she had a complaint to investigate while she was here. I, (First and Last Name of the former NHA) was then informed by (First Name of DON) and (First and Last Name of Local state agency worker) that an allegation had been made that a former SNF (Skilled Nursing Facility) resident (First and Last name of Resident #59) had a large bruise on her abdomen and flank area and that she had multiple pressure wounds at various stages, which was believed by the complainant to have occurred at (Name of Nursing Facility). (First Name of the DON) reviewed the residents chart, finding no documentation indicating there were any bruises or pressure areas on the resident prior to her leaving the facility on (date omitted to protect confidentiality). All documentation related to the resident's skin condition completed by nursing staff, physician, FNP (Family Nurse Practitioner) indicates that the resident had no skin issues [NAME] at (Name of the Facility). Statements from nursing staff who provided care to Ms. (Last Name of Resident #59) during her stay at (Initials of the Nursing Facility), indicate that the resident's skin was intact and at no time was any bruises, skin tears, or pressure ulcers observed by any direct care staff. Ms. (Last name of Resident #59) was admitted to the facility on (date omitted to protect confidentiality) for SNF for a short term rehab (rehabilitation) stay following a hospitalization. She had resided at a (Name of a local behavioral health home) home and needed therapy prior to returning to her formed residence. Her participation in therapy was minimal and she required a lift when transferring. On or about (date omitted to protect confidentiality) (First and Last Name of the admissions coordinator), Admissions Coordinator, received a call from a nurse at the (Name of local Behavioral Health Company) home, where Ms. (Last name Resident #59) lived, demanding that the resident be returned to them immediately. (First name of the Admissions Coordinator) explained that there was a process that we needed to follow before we could just release the resident. (First name of the Admissions Coordinator) called (Local State Agency) worker, (First and Last Name of State agency worker) informing her of the call from the (Name of Local Behavioral Health Company) nurse. (First Name of Local State agency worker) told (First name of the Admissions Coordinator) to proceed with the process to discharge Ms. (Last name of Resident #59) back to the (Name of local Behavioral Health Company) home and discharge plans were initiated, resulting in Ms. (Last name of Resident #59) returning to her previous residence on (Date omitted to protect confidentially). On 02/12/24, (First name of Admissions Coordinator) received a new referral from (Name of local Hospital) for Ms. (Last Name of Resident #59), as she had returned to the hospital on [DATE] ( please note the resident actually returned to the hospital on [DATE]) from her (Name of local Behavioral Health Company) home. (First Name of admission coordinator) informed (Initials of Local Hospital) that we had an available bed and would accept her back. (First Name of admission Coordinator) reviewed the hospital records, which had no documentation of the wounds that ad been reported to the (Name of Local State agency). The resident did not return to this facility, and it is unknown to where she was transferred. Findings: It is determined that the allegations made are unsubstantiated, as there is no documentation or staff observation to support them. Further review of the reportable found no hospital records attached to the incident. In addition there was no evidence the facility had reached out to the Behavioral Health Company or the hospital to receive statements as to the residents condition. The state survey agency requested Resident #59's medical record related to her hospital stay which began on 02/07/24. When the records were received and reviewed it was determined the pressure wounds were mentioned abundantly in the hospital record. Examples are as follow, 02/07/2024 - ED (Emergency Department) to Hosp-admission (discharged ) in (Name of local hospital) (continued)Discharge Summary Note (continued) . REASON FOR HOSPITALIZATION AND HOSPITAL COURSE Brief HPI(history or present illness) : This is a (Age Redacted to maintain confidentiality) y.o. (year old), female admitted for hypernatremia. Patient presented to the ED for developing wounds on the sacrum and heels. She was recently discharged from the (Name of Facility) and admitted to (Name of local behavioral health) group home. It was reported that she is requiring too much care to be cared for in a group home and would do better in a nursing home setting An emergency room triage note read as follows (typed as written) , 'RECENTLY D/C (discharged ) FROM (Name of Facility) to (Name of behavioral health company. (Name of Behavioral Health Company) STAFF SENT PT (Patient) TO ER FOR DECUBITUS WOUNDS THAT THEY WOULD LIKE TO BE STAGED These are a couple of examples from a hospital record that referred to wounds a total of 820 times. An interview with the current Nursing Home Administrator and Director of Nursing on the afternoon of 02/12/25 confirmed the investigation was not thorough. At the time of exit on 02/13/25 the Corporate Registered Nurse provided the surveyor with a plan of correction (POC) related to not completing thorough investigations she stated, We identified this was an issue and believe we have corrected it and would like this to be past non compliance. The facility presented their plan of correction which read as follows, Abuse Neglect POC: 11/18/24 for QAPI (Quality Assurance Performance Improvement) approval on 11/21/24. During survey preparation and review audits it was discovered that there were some discrepancies in facility reportable events. The discrepancies include, timely reporting, full investigations conducted, reporting the initial to all parties including OHFLAC, APS, Ombudsman, Local law enforcement, sending in a 5- day follow up to all parties. A POC was initiated on 11/18/2024. With the following interventions: Staff will be re-educated regarding the abuse neglect policy and procedure. Staff will also re re-educated about being mandated reporters and reporting any abuse/neglect in a timely manner. Failure to follow the POC for reporting by any staff member will result in disciplinary action. Resident residing in the facility as of 11/18/2024 will be interviewed regarding any signs or symptoms of abuse/neglect. Any areas of concern will be reported to the appropriate parties and investigated for resolution. Any concerns noted from the interviews will also be addressed by the facility staff for resolution. Any concerns/grievances will be reviewed at morning meeting to ensure that the issues are being addressed and to ensure that if there are signs or symptoms of abuse neglect that they have been reported appropriately. The NHA/Designee will audit the concern grievance log and FRI (Facility reportable incidents) book monthly to ensure that all areas of concern have been resolved appropriately and reported as necessary for the next 3 (three) months. The results of the audit will be presented at the monthly QAPI committee meeting for review and further follow up if necessary. The implementation of the POC was reviewed by the surveyor and confirmed record review and staff interviews therefore this tag is cited at past noncompliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident representative interview, staff interview, hospital staff interview, long term care ombudsman interview and record review the facility failed to ensure Resident #60 who was discharged from their facility and was expected to return was readmitted to the first available bed when medically stable. Resident #60 has remained in the hospital from [DATE] until the time of this survey. The facility has admitted other male residents instead of Resident #60 with claims they did not have suitable bed for him. Resident #60 has experienced actual psychosocial harm as a result of these failures. The resident has experienced anxiety, agitation, and feelings of despair thinking he has done something wrong to cause this. This was true for one (1) of three (3) facility residents whom were reviewed during this complaint survey. Resident Identifiers: #60. Facility Census: 58. Findings Include: a) Resident #60 On 01/28/25 the state survey agency received a complaint indicating Resident #60 was discharged from the facility with a return anticipated and the facility has refused to readmit him with claims of not having an appropriate bed for him. The complaint had indicated the long term care ombudsman was also involved and the facility has still not allowed this resident to return. On 02/10/25 the long term care Ombudsman for this facility spoke with the surveyors. She indicated she became involved in this situation after Resident #60's wife had reached out to her. She stated, she had been to the facility on two separate occasions and met with staff to determine why they would not readmit Resident #60. She stated, they never tell me they won't take him back they just keep saying they don't have an appropriate bed for him. She further stated, I know they have admitted a total of eight (8) residents five (5) females and three (3) males since Resident #60 was cleared for discharge from the hospital. She indicated, the resident was feeling anxious and depressed that he did not understand why they would not take him back and is wondering what he has done to cause this. She stated, he wants to come back to this facility because he has friends here and he is allowed to smoke at this facility. She indicated the residents elderly parents and wife are local and do not want him to be so far away they could not visit regularly. On 02/10/25 in the afternoon the surveyor spoke with the Hospital Case Manager #70 (HCM) via telephone. HCM #70 stated she as spoken with the facility on numerous occasions about Resident #60 and they just keep telling me they don't have an appropriate bed for him. She stated, I know they have admitted residents since he has been ready for discharge. She stated, we have tried placing him at other facilities but they will not take him because of his pain pump. She stated the resident is having a hard time with it because he doesn't understand why they will not take him back. HCM #70 stated she would provide the surveyor with the notes related to their communication with the facility. A review of Resident #60's hospital medical record found the following notes from the case management department. -- Note dated 12/31/24 read as follows: Pt (Patient)is alert and verbal. He is requesting to return to SNF (Skilled Nursing Facility). Wife's goal is for pt to return to facility. CM(Case manager) has spoken with (First and Last Name of the facility admission Director),Admissions at (Name of Facility). She confirms that pt can return to SNF when medically ready. Updated medicals have been submitted via Care port. The patient will continue to be evaluated for developing discharge needs. -- Notes dated 01/02/25 read as follows: CM attempted to reach (First and Last Name of the Facility admission Director),,Admissions Director with (Name of Facility) three times and left repeated messages. (First name of admissions director) called back and advised that they do not have a bed for pt today but do plan to accept him back as soon as bed becomes available. CM will continue to follow. (Please note the facility admitted a new admission on this day who was male Resident #61. He was admitted to a private room and was a new admission to this facility.) -- Note with a date of service of 01/06/25 which was entered on 01/08/25 read as follows: CM spoke with (First name of Facility Employee) at (Name of facility). She transferred call to (First and Last Name of the Facility admission Director) who did not answer. She did contact this CM later to advise that they had no beds today. Pts wife/MPOA did call (Initials of another local nursing home), Admissions Director,(First and last name of the other local nursing home)today to look for a bed there for pt. (First Name of admissions director at the other local nursing home) called this CM requested medicals. After viewing pts records in Care Port,(First Name of admissions director at the other local nursing home) called back to advise that the open bed they had at (Initials of another local nursing home) was filled earlier today. PAS was also done today. --Note dated 01/08/25 read as follows (This note was written by HCM #71 all previous notes referenced were written by HCM #70): Received this patient into CM service this am. Patient is discharged . Patient is admitted from (Name of this facility). However, (Initials of this facility) does not currently have a room available for return. Spoke with (First and Last Name of the Facility admission Director),@ (Initials of Facility) who advised will have bed available possibly 01/11/2025. Secondary to medical stabilization, this CM will seek appropriate NF placement. -- Note with a date of service of 01/08/25 filed in record on 02/12/25 written by HCM #70 read as follows: Pts wife/MPOA,(First name of Resident #60's wife) visited with this CM today. CM has left message for (First name of Admissions director at this facility),inquiring about bed status. She advised that she is calling (First and Last Name of the Facility admission Director), daily to inquire about a bed for pt. She stressed that he wants to return there. He is also reportedly calling his friend at facility daily. CM will continue to follow. -- Note dated 01/10/25 written by HCM #71 read as follows: Contacted (First name of Admissions director at this facility)@ (Name of this facility)this am to obtain status of possible bed placement today. Left message. Awaiting call back. (Please note that on 01/09/25 Male Resident #20 was admitted to the facility. Resident #20 was a new admission to the facility.) -- Note dated 01/13/25 written by HCM #71 read as follows: Spoke with patient's wife, (First and last Name of Resident #60's wife), this am re: lack of success in returning patient to(Name of this facility) Center. Notified wife of need to place patient possibly out of area. Wife voiced understanding. Stated she did not have 2400.00 for bed hold and this is all about money. This CM will send referral out regionally for NF placement. 8:45 AM Uploaded clinical info and sent out to regional nursing facilities. Awaiting bed placement offer. 11:29 AM Received t/c from (First and last name of nursing home corporation), Liaison who is seeking possible bed placement in (First name of nursing facility corporation) Health facility. Continue to await bed placement offer. --Note written on 01/13/25 by HCM #71 read as follows: Patient admitted from (Name of Nursing Facility). Cannot return due to no bed availability secondary to no bed hold in place. Referral made in Care port for placement throughout the State. Spoke with (First and Last name of nursing facility corporate liaison #72), Liaison with (Name of nursing facility corporation) this am re: bed availability. (Liaison #72) reports no bed available in state to accommodate ESBL and Influenza at this time. (Liaison #72) will continue to look for bed placement. -- Note written on 01/15/25 by HCM #71 read as follows: Received corporate denial from (Name of nursing facility cooperation) Health secondary to patient having active pain pump, having recent BHP (Behavioral Health) stay, and altercation with other resident at NF were reasons provided by (Liaison #72) for corporate denial. (Please note it was this date the Director Of Nursing (DON) advised they had spoke with this cooperation about Resident #60) Also on this date the facility admitted female Resident #24 to a private room. Resident #24 was a new admission to this facility. -- Note written 01/16/25 by HCM #70 read as follows: CM received message this afternoon that (Name of facility's sister facility) SNF had a bed for this pt. CM called facility and spoke with (Name of Sister Facility's Admissions,Admissions Director. She advised that admissions person covering for her yesterday(First and Last name of staff covering admissions at sister facility) offered a bed,however admissions team determined that they can not accept pt with a pain pump because their staff is not trained to manage. CM will continue to follow for discharge planning. -- Note written on 01/20/25 by CM has spoken with (First and Last name of the admissions director of this facility),(Name of this facility). Pt remains on their waiting list. She does not have an appropriate male bed today. CM will continue to follow for discharge planning. (Please note on 01/17/25 the facility had Male Resident #69 discharge and Female Resident #64 was admitted to a private room. Resident #64 was new admission to the facility.) -- Note written on 01/23/25 by HCM #70 read as follows: CM received call from (First and Last),Ombudsman today. She advised that if (Name of this facility) has no beds, she would recommend (Name of another facility in a connecting county)because pt would be permitted to smoke there. CM spoke with (Corporate name of Facility in connecting county)Admissions Liaison after talking w/Ombudsman. He advised that, to date 15 of the (Name of Cooperation who owns facility in connecting county) facilities have declined pt d/t not having clinical capability to manage pain pump. (Facility in connecting) is one of those facilities. (Please note on 01/21/25 the facility admitted male Resident #65 to a private room. Resident #65 was a new admission to the facility.) -- Note also written on 01/23/25 by HCM #70 read as follows, CM received a follow up call from (First and last name of ombudsman),Ombudsman. She advised that she has been to (Name of Facility) to follow up on bed status for this pt and found them to have no bed for pt at this time. She explained that she will follow up with (Name of corporation who own nursing home in connecting county) Management to determine if they will consider pt for one of their facilities. (Name of corporation who own nursing home in connecting county) Liaison has advised that company is concerned about documentation in pt record that notes that pts family has brought in THC (Marijuana) gummies for pt. This CM spoke with pts wife/MPOA at length r/t this concern. She assured CM that no family member has provided pt with any gummies. Pt reportedly brought CBD (Cannabidiol) (CBD is legal to purchase and use) gummies with him when he was admitted to (Name of nursing home) in May 2024. Wife reports that she was unaware that pt had gummies in his possession. Staff reportedly found gummies and took them from pt. Family was reportedly agreeable to this. Wife stresses that pt has never done drugs or been supplied any by family members. CM left message for (First and Last Name of Ombudsman) regarding conversation with pts wife. (Please not that the facility admitted Male Resident #66 on 01/27/25 to a private room. Also on 01/27/25 the facility admitted Male Resident #58 on 01/27/25 to a private room.) - Note with a date of service of 01/29/25 which was entered into the record on 02/12/25 by HCM #70 read as follows, CM spoke with (First and Last of ombudsman,Ombudsman via telephone on 1/27/25 to check the current discharge status of this pt. She has called this morning to again determine the status of this pt and confirm conversations r/t pts return to (Name of Nursing facility) between this CM and Admissions Director. (First name of the Ombudsman) is going to (name of facility) this morning to meet with administration r/t possibility of this pt returning there. -- Note dated 01/31/25 written by HCM #70 read as follows: CM received a message from (First and Last Name of ombudsman),Ombudsman today. She advised that she came to (Initials of Hospital) and met with pt today. She also asked if (Name of facility) is assisting CM in finding alternate placement for Mr. (Last name of Resident #60), if they are not going to take him back? CM returned call and left voice message advising that (Name of facility) has not been assisting CM in finding placement. (Please note also on 01/31/25 the facility had a male discharge Resident #61 discharge on this date). (Please note the facility admitted Male Resident #35 on 02/03/25 this resident was new admission to the facility) -- Note dated 02/07/25 written by HCM #70 read as follows, (First and Last Name of Ombudsman),Ombudsman called this CM today to check status of this pt. She advised that she has attempted to reach (Name of Facility) Administrator via telephone but has not received a call back from him. She asked if CM can follow up with (Name of another sister facility of this facility which is two and one half hours from this facility)(sister facility to (Name of Facility)) because she has been told that they may accept pt until he can be moved back to (Name of this Facility). CM also spoke with (First and Last Name of nurse for a state program that helps people transition home), RN with (Name of state program that helps people transition home). She explained that they have sent information in to the state. Due to heavy case load they routinely take about 1 month to process and make RN visit to pt. (Name of state program that helps people transition home then goes in to see pt for their assessment.) (Please note on 02/06/25 Male Resident #49 to a private room. Resident #49 was a new admission to this facility.) Further review of Resident #60's hospital records found the following note written by the hospitalist that contained the following: 02/02/25- pt is mildly agitated, today stating he doesn't understand why he is stuck here and facilities won't take him just because he has a pain pump. Explained policy to him and told him that case mgt is still working on placement. 02/03/25- no complaints today, case management working on placement at this time. 02/04//25- case management working on personal care workers for home, possibly. No complaints, today. Upon entrance to the facility on [DATE] it was noted by surveyors Male Resident #58 was in (Room Number redacted to maintain confidentiality) in the B - Bed and the A- bed was empty. Resident #60 could not have had any conflicts with this resident because Resident #58 was not admitted to the facility until 01/27/25. Resident #58 was moved into room (room redacted to maintain confidentiality) B - Bed on 02/07/25. On 02/11/25 the facility moved Male Resident #49 into (room number redacted to maintain confidentiality) a- bed. The a -bed with Resident #58 was available from 02/07/25 until 02/11/25 and Resident #60 was not offered this bed. From 01/02/25 until 02/07/25 the facility admitted a total of seven (7) males who were all new admissions. In addition they admitted a total of six (6) female residents into private rooms which Resident #60 could have been admitted to. A review of Resident #60's medical record from the facility found he was discharged to the hospital on [DATE]. The discharge Minimum Data Set (MDS) with and assessment reference date of 12/29/24 indicated the resident was discharged with a return anticipated. A further review of the residents medical record found he had exhausted all of his medicaid provided bed hold days prior to his discharge on [DATE]. Additional correspondence with the Long Term Care ombudsman for this facility found the Acute Care Hospital sends out a list daily to all Skilled Nursing Facilities of patients they have ready for discharge,in the area and Resident #60's name has been included on that list daily beginning on 01/07/25. She confirmed this facility would have received the list daily. In the after noon of 02/13/25 the Director of Nursing (DON) and Nursing Home Administrator (NHA) provided the following time line explanation as to why they have not readmitted Resident #60 to the facility. -- 11/20/24 (First and Last Name of Resident #60) reports (First and Last Name of Resident #16) entering his room. Stop sign provided. -- 11/21/24 (First and Last Name of Resident #27 grievance r/t (related to) roommate (First and Last Name of Resident #60) keeping him up at night. (First name of Resident #27) denies a room change. -- 11/29/24 Res to Res reportable (First and Last Name of Resident #60) vs (First and Last name of Resident #16) Verbal disagreement started by (First Name of Resident #60) and then (First name of Resident #16) at (First and Last Name of Resident #60) (First name of -- Resident #16)kicks at (First Name of Resident #60).(Please note this was reported to the State agencies and Resident #16 was listed as the perpetrator. -- 12/09/24 (First and Last Name of Resident #61)referral begins with bed offer made. (Please note this was 20 days before Resident #60 was discharged to the hospital.) -- 12/16/24 Res to Res reportable(First and Last Name of Resident #60) vs (First and Last name of Resident #16) (Please note: This reportable lists Resident #60 as the perpetrator Resident #16 kicked at Resident #60.) -- 12/20/24 Verbal disagreement (First and Last Name of Resident #60) vs (First and Last name of Resident #16) -- 12/24/24 (First and Last Name of Resident #60) goes out with family for overnight visit. -- 12/26/24 IDT reviewed (First and Last name of Resident #60)'s continued difficulties with (First and Last Name of Resident #16) and offered room change to 102 to minimize opportunities for interactions with her. He (Resident #60) accepted. (Please note this was a private room and was the room the resident was in at the time of his discharge. Resident #60 also does not have capacity and his wife/MPOA was not notified of this room move.) -- 12/29/24 (First and Last Name of Resident #60) d/c (discharge) to hospital with no bed hold days remaining. -- 01/02/25 (Initials of Acute Care Hospital) management posts in Care Port for (First and Last name of Resident #60) update. No discharge info provided. Census 60. (Care Port documentation listed Resident #60's projected discharge date as 01/01/25). -- 01/03/25 (Initials of acute care hospital) Case management posts in Care Port for (First and Last name of Resident #60).No discharge info provided. Census 60. (Care Port Documentation listed the projected discharge date as 01/02/25) -- 01/05/25 (First and Last Name of Resident #20) referral received. -- 01/06/25 (Initials of acute care hospital) Case Management calls for (First and Last Name of Resident #60) update. No discharge info provided. Census 59 with 1 paid bed hold. -- 01/07/25 (Resident and Last name of Resident #20) began prior auth process and bed offer made. -- 01/08/25 (initials of acute care hospital) Case Management calls for (First and Last name of Resident #60)update. Potential discharge planned for 1 /11/25 that would open a bed for (Resident #60). Census 60. -- 01/08/25 (First and Last Name of Resident #70 ) passes away. Census 59 with room [ROOM NUMBER] A male bed open. -- 01/09/25 (First and Last Name of Resident #20)admits to 124 A. (First and Last Name of Resident #58) referral received. -- 01/10/25 (Initials of Acute Care Hospital) Case management calls for (First and Last Name of Resident #60) update. No discharge info provided. Census 60. --01/11/25 (First and Last name of Resident #69) did not discharge. Rescheduled discharge for 1 /17 /25. -- 01/12/25 (First and Last Name of Resident #63) referral received. -- 01/13/25 (Initials of Acute care hospital) Case management posts in Care Port for (First and Last Name of Resident #60) referral. He is ready for discharge. Admissions spoke with (First and Last name of Resident #60's wife) to offer sister facilities. (First name of Resident #60's Wife) declined, stated that she did not want him that far away. Census 59, female bed open 118 A.(Please note one of the sister facility offers declined to admit Resident#60 and the other one was two and one half hours away from the residents wife and his parents) -- 01/15/25 (First and Last name of Resident #63) admits to 118 A. -- 01/15/25 Admissions receives call from (Name of Corporation who owns numerous nursing home in the area) about (First and Last name of Resident #60) and we believed that they would admit him based on the conversation. -- 01/16/25 (First and last name of Resident #64) referral received and bed offer made. -- 01/17/25 (First and Last name of Resident #69) discharge. (First and last name for Resident #64)admits. Census 60. -- 01/20/25 (Initials of Acute care hospital) Case management calls about (First and last name of Resident #60) and informed us that he was still at (initials of acute care hospital) Census 58. 117 A male bed (First and Last Name of Resident #4) roommate, not compatible previously 07/30/24 and 118 A female bed. -- 01/21/25 (First and Last name of Resident # 61) moves to 117 A, leaving 110 B (male bed) open. (First and last name of Resident #44) in 110 a ((First and Last Name of Resident #60)previously not compatible) (First and last name of Resident #65) admits to 110 B. (First and Last name of Resident #50) readmits with C Diff. Census 60. -- 01/21/25 We had no further contact with the hospital about (First and Last name of Resident #60) since 1 /21/25. Census 60. -- 01/23/25 Ombudsman reports to (Initials of the acute care hospital) that we had no bed. Census 60. -- 01/26/25 First and Last Name of Resident #71) discharge. Census 59. (Female bed open) -- 01/27/25 Census 57 plus 2 bed holds.(First and last name of Resident #58) admits. -- 01/29/25 Ombudsman in facility. No open beds. Census 58 plus 2 bed holds. During a telephone conversation with Resident #49's wife on 02/10/25 she stated, I don't know why they won't take him back. She indicated that he is really upset about this. She indicated he has anxiety because he thinks he has done something wrong to make them not want to take him back. She said he was worried he will have to go somewhere further away and his parents won ' t be able to visit him. She stated, he has friends there and he can smoke there and he is very worried about not being able to go back there. She stated, he calls people there and they tell him they are admitting people which adds to his anxiety. The facility maintained they did not know he was ready for discharge on several dates and even noted they had not had contact with the hospital sine 01/21/25 however it was confirmed by the ombudsman and hospital they received a list daily from the hospital about residents ready for discharge and Resident #60's name was on that daily list every day beginning on 01/07/25 moving forward. The DON and NHA indicated they have never had a bed to admit Resident #60 in to and claim the time line above explains why. However there the facility was presented with numerous opportunities to readmit the resident and instead chose to admit residents who were new admissions to the facility.

Based on resident interview, record review, and staff interview, the facility failed to allow residents to make choices important to them. This deficient practice had the potential to affect one (1) of 21 residents in the long-term care survey sample. The facility did not honor Resident #49's choice as to when to have his dressing changed. Resident identifier: #49. Facility census: 58. Findings included: a) Resident #49 Review of Resident #49's physician's orders showed an order written on 12/26/24 to Cleanse unstageable ulcer to outer right ankle with wound wash; allow to dry; apply Medihoney, cover with bordered foam, every night shift for wound healing until healed. Review of Resident #49's progress notes showed a nurse's note written on 1/4/2025 at 4:13 AM, which stated, Cleanse unstageable ulcer to outer right ankle with wound wash; allow to dry; apply Medihoney, cover with bordered foam, every night shift for wound healing until resolved. Resident refused TX [treatment] stating that if the nurse wanted to do his treatment, then she should have came into do it at a more appropriate time. Following this, the resident's unstageable ulcer dressing change was performed on the following dates and at the following times: - 01/05/25, at 12:02 AM - 01/05/25, at 9:04 PM - 01/06/25, at 9:57 PM (The dressing change time was not specified on 01/07/25, 01/08/25, and 01/09/25). - 01/10/25, at 11:04 PM - 01/12/25, at 3:38 AM - 01/13/25, at 3:43 AM On 01/08/25 at 10:51 AM, Resident #49 was interviewed about his pressure ulcer. When specifically questioned, the resident stated his dressing change was performed at night. He stated night shift dressing changes were not his preference and he did not like being awoken up for dressing changes. Resident #49 asked if this surveyor would ask the nurses if his dressing could be changed when he did not need to be woken from sleep. During an interview on 01/13/25 at 2:45 PM, the Director of Nursing stated Resident #49's dressing change was scheduled for night shift per the resident's request. She acknowledged the progress note written on 01/04/25 documented that the resident did not want to be awakened for dressing changes, but the resident's dressing was changed at 3:38 AM on 01/12/25 and at 3:43 AM on 01/13/25. No further information was provided through the completion of the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate bed hold notice was given to the resident representative when Resident #60 was transferred to the emergency room. This was true for one (1) of three (3) residents reviewed for the care area of hospitalizations during the long-term care survey process. Resident Identifier: #60. Facility Census: 58. Findings Included: a) Resident #60 A review of Resident #60's medical record on 01/08/25 found she was discharged to the emergency room on [DATE]. A copy of the resident's bed hold notice which was sent to the resident representative was requested on 01/09/24. The bed hold notice when provided was not complete. The notice contained the resident's name and medical record number and was signed by the nurse. The bed hold notice did not identify if Resident #60 had any behold days available to her from her insurance and the rate per day was not identified should the resident's representative want to pay privately to hold the bed. Furthermore, there was no indication this notice was sent and/or discussed with the residents representative to allow them to make an informed decision about holding the residents bed. On the afternoon of 01/09/25 the admission coordinator was asked if there was another bed hold notice that was sent to the representative or if there was any documentation to suggest this was discussed with the representative. At the time of the exit no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #60's and Resident #59's Minimum Data Set (MDS) were accurately completed. This was true for two (2) of 21 sample residents reviewed during the long term care survey process. Resident Identifiers: #59 and #60. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record on 01/14/25 at 10:00 AM, found the resident was discharged home on [DATE]. The son had asked the facility to prepare for the discharge on [DATE]. The facility made all arrangements for the discharge including a referral for home health. The Discharge MDS with and Assessment Reference Date (ARD) of 12/05/24 found the MDS identified the residents discharge as unplanned, even though the discharge was planned. An interview with the Director of Nursing (DON) on 01/14/25 at 10:58 AM confirmed the MDS was not coded accurately. b) Resident #60 A review of Resident #60's medical record on the morning of 01/14/25 found a Weekly Wound evaluation dated 11/15/24 which identified the resident had suspected deep tissue injury located on sacrum. The wound was identified on 11/15/24 and was identified as being facility acquired. A review of Resident #60's MDS with an ARD of 10/11/24 found the residents suspected deep tissue injury on the sacrum was coded to reflect the wound was present on admission, however the wound was in fact facility acquired. During an interview with the Director of Nursing (DON) on 01/14/25 at 10:58 AM, she confirmed the MDS was inaccurate.

Based on record review and staff interview, the facility failed to identify medical diagnoses of Major Depressive disorder on the Preadmission Screening and Resident Review (PASARR). This was found true for one (2) of three (3) residents reviewed under PASARR care area. Resident identifiers: #40 and #30. Facility census 58. Findings included: a) Resident #40 On 01/07/25 at 3:21 PM record review found the following medical diagnosis: Schizoaffective Disorder, Bipolar type, and Major Depressive Disorder. Further record review on 01/07/25 of the PASARR revealed major depressive disorder was not identified on the form. An interview on 01/08/25 at 9:55 AM with the Director of Nursing (DON) who confirmed the PASARR was incorrect and did not contain major depressive disorder. b) Resident #30 A review of Resident #30's medical record on 01/14/25 found the resident's medical diagnosis list included the following: Unspecified Dementia, Bipolar Disease, and epilepsy. Further review of the record found a PASARR dated 07/07/24 did not identify the resident having a diagnosis of dementia, bipolar disorder and/or epilepsy. On 01/15/25 at 9:38 AM an interview with the Social Worker confirmed the PASARR did not contain an accurate listing of the diagnoses.

Based on record review and staff interview, the facility failed to implement the care plan for Resident #19, by failing to identify triggers for behaviors. This was true for one (1) of twenty-one (21) resident care plans reviewed during the survey process. Resident identifier: #19. Facility census: 58. Findings included: a) Resident #19 At approximately 10:00 AM on 01/09/25, during a review of Resident #19's record, it was noted the care plan had a focus for behaviors. The care plan read as follows: Focus- BEHAVIORS: the resident has behaviors of delusions: fixed false beliefs despite evidence that they are untrue, hallucinations: visual, auditory or other, often makes false allegations, often talks about people wanting to have inappropriate behaviors with her. Date initiated: 11/28/2024 Revision on: 01/08/2025. Goal- The resident's behaviors will cause them less distress thru the review period. Date Initiated: 11/28/2024. Target Date: 04/06/2025. Interventions: -administer medications as ordered. Date initiated: 11/28/2024. -Approach with a calm quiet voice, divert attention, and remove from the situation and take to an alternative location as needed. Date initiated: 11/28/2024. -Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situations. Date initiated: 11/28/2024. During review of notes for psych visits for Resident #19, the following was noted from the consult notes: -Ex-husband was physically abusive. -Patient states she has a bad temper due to men coming and looking into her window and hiding under her bed. Patient states she does not have a good appetite due to believing that people are putting things in her food and drinks to poison her. At approximately 1:10 PM on 01/14/25, during an interview with the Director of Nursing (DON), it was determined the resident's delusions started when she was diagnosed with a UTI and continued after she was treated. However, the facility had not attempted to identify the resident's triggers.

Based on record review, observation, resident interview, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (5) five residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier #34. Facility Census 58. Findings Included: a) Resident #34 During the initial observation and interview on 01/07/25 at 2:15 PM, Resident #34's teeth were covered with a white substance with some black spots. Resident #34 stated, I can not tell you when the last time they brushed my teeth. I cannot do it myself. I do have a tooth brush in here, but I cannot tell you where it is. A record review on 01/08/25 at 1:30 PM, of Resident #34's Brief Interview for Mental Status (BIMS) score, dated 12/17/24 revealed a BIMS score of 14. Further record review revealed Resident #34's last dental consult was on 12/19/24, and included a hygiene note that reads as follows: Very heavy plaque, calculus and food debris. Recommend assistance with daily Oral Hygiene (OH). This recommendation was signed off on by a Registered Nurse (RN). A review of Resident #29's care plan on 01/09/24 at 9:30 AM, revealed the following care plan related to ADL care: Focus: The resident is a long term care resident and requires assistance with their ADL's related to chronic health conditions. Date initiated 12/11/24 Intervention: Oral care with assistance daily. Date Initiated 12/11/24. Revision on 12/24/24. During an interview on 01/09/25 at 10:37 AM, Nurse Aide (NA) #48 stated, I do mouth care when i give them a shower During an interview on 01/09/25 at 10:38 AM, NA #47 stated, I typically do mouth care and shave them when I am doing their shower. During an interview on 01/09/25 at 10:50 PM, Licensed Practical Nurse LPN #75 confirmed that Resident #34's teeth were dirty and that she needed oral care. A record review on 01/09/24 at 12:00 PM, of the task list for Resident #34 revealed that her shower days are on Monday's and Friday's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to prevent, identify, assess, and treat pressure ulcers in accordance with professional standards of treatment. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #6. Facility census: 58. Findings included: a) Resident #6 Review of Resident #6's medical records showed the resident returned to the facility on [DATE] after a hospital stay. A nursing note written on 12/26/24 at 2:56 PM stated the resident had a Pressure area to left buttock. A nursing note written on 12/26/24 at 3:10 PM stated the resident had an Open area to left buttock. The readmission Nursing Collection Tool dated 12/26/24 documented the resident had a pressure ulcer to the left buttock, measuring two (2) centimeters (cm) in length by two (2) cm in width. The depth and the stage were not documented. The Licensed Nurse Weekly Skin Observation dated 12/26/24 stated, Resident readmitted today from [hospital name] with multiple scabbed areas to bilateral arms and legs. Skin tear noted to left forearm. Open area noted to left buttock. Scabbed area noted to right foot and left ankle. A physician's order was written on 12/26/24 to Cleanse pressure injury to left buttock with wound wash, let dry, apply Medihoney to wound bed and cover with bordered gauze QD [every day] every night shift for wound healing until healed. The resident's Treatment Administration Records (TARs) and Medication Administration Records (MARs) for December 2024 and January 2025 did not have the order for Resident #6's pressure ulcer treatment on them. Therefore, there was no documentation the treatment had been performed. The Licensed Nurse Weekly Skin Observation dated 01/01/25 stated, 3 scabs observed to L [left] elbow going around his arm. 1 scab on R [right] wrist. 1 scab on back of R [right] elbow. ST [skin tear] to LLA and back of RUA [right upper extremity]. R wrist remains swollen. No documentation of pressure ulcer treatment could be located in the resident's medical record. No further assessment of the pressure ulcer could be located in the resident's medical records. No staging of the pressure ulcer could be located. The resident was transferred to the hospital on [DATE]. On 01/15/25 at 3:28 PM, the Director of Nursing (DON) confirmed there was no further documentation of resident's pressure ulcer assessment and treatment from the resident's admission on [DATE] through his transfer on 01/08/25. No further information was provided through the completion of the survey. b) Policy review The facility's policy titled Pressure Injury Prevention and Management with no implementation date given and revision date 05/22/23 stated as follows: - Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner.

Based on record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. This was true for one (1) of two (2) residents reviewed for the care area of tube feeding during the long term care survey. Resident Identifier: #60. Facility Census: 58. Findings Included: a) Resident #60 1. Residual Order A review of Resident #60's medical record on the morning of 01/14/25 found the following physician order: Enteral Feed Order: every shift Check feeding tube residual every (provider please specify) Hold tube feeding if residual is greater than (provider to specify). This order had a start date of 01/08/25 and was the current order at the time of this review. An interview with the Director of Nursing at 10:58 AM on 01/14/25 confirmed the order to check the resident's residual of her feeding tube was incomplete. The provider failed to specify the number of times the residual should be checked or when the feeding should be held. 2. Amount of Feeding A review of Resident #60's medical record on the morning of 01/14/25 found a physician's order which read: -- Enteral Feeding Jevity 1.5 cal 300 milliliters (ML) via peg tube five times a day . This order had a start date of 12/16/24. A review of the Medication Administration Record (MAR) from 12/16/24 through 12/20/24 found nursing only provided 237 ML of Jevity on each feeding beginning at 6:00 PM on 12/16/24 through the 6:00 PM feeding on 12/20/24.

Based on record review and staff interview, the facility failed to implement non-pharmacological interventions for behaviors exhibited by Resident #19. This was true for one (1) of one (1) residents reviewed for behaviors during the survey process. Resident identifier: 19. Facility census: 58. Findings included: a) Resident #19 During a review of Resident #19's record on 01/09/25, multiple episodes of psychosis were noted.The facility documented behaviors in the progress notes section of the resident's record. Upon review of those behavior notes, it was determined the facility staff was attempting to redirect the resident and, if that did not work, no other non-pharmacological interventions were attempted. During a review of Resident #19's orders, it was noted the resident had an order, beginning on 12/30/24, for behavior monitoring and, included in the order, were eight (8) non-pharmacological interventions. The interventions are as follows: (1) Redirect (2) 1:1 (3) activities (4) toilet (5) give food or fluids (6) reposition (7) back rub (8) other-chart in progress notes. The following are behavior monitoring notes, typed as written in the resident record, from October 2024 through January 2025 (Most recent episodes are listed first). The staff members list the type of behavior, how much it occurred during the shifts, and any interventions attempted, along with the effectiveness. The notes included have interventions noted as being ineffective, slightly effective, or list no effectiveness. Behavior notes: 01/13/25 12:59 *Behavior Note Please describe the behavior demonstrated:Resident continues holding conversations with people not present in room. Believes man is hiding under bed and is talking to her. Resident is suspicious of staff entering room stating don't take any of my things. How often did this behavior occur/last: intermittently Describe any interventions attempted:: Reassured Resident of her safety. Assured Resident staff would not take her belongings. Effectiveness of Interventions:: Behavior continues. 01/13/25 21:13 *Behavior Note Please describe the behavior demonstrated:: Resident Telling various staff to get out when going into room Stating they are just trying to steal from her and they need to get out. How often did this behavior occur/last: various times when staff goes into room Describe any interventions attempted:: This nurse Talked to resident and reassured her that no one is going to try and steal her belongings. Effectiveness of Interventions:: non-effective. 01/10/25 00:05 *Behavior Note Please describe the behavior demonstrated:: Resident complaining to nurse that the crazy girl has been poisoning her. and it was starting to sip out of her skin. When asked who the girl was resident stated you know the two girls who like to cause trouble. How often did this behavior occur/last: X2 Describe any interventions attempted:: Attempted to reorient resident. Effectiveness of Interventions:: Non-effective. 01/09/25 09:59 AM Resident exhibiting multiple behaviors, such as, feeling someone is poisoning her food, people living under her bed, believing people are cutting themselves in the hallway. Staff documents trying only one non-pharmacological intervention. Staff not documenting trying more than one intervention when one is unsuccessful. 1/9/2025 00:43 *Behavior Note Please describe the behavior demonstrated:: Resident stating that nurse is trying to poison her and give her someone else's medications. That Nurse was not working with her. She also stated that there was some man down the hall cutting himself and that she just couldn't help him How often did this behavior occur/last: At Various times. Describe any interventions attempted:: attempted to redirect. Effectiveness of Interventions:: Non-effective. 1/7/2025 12:47 *Behavior Note Please describe the behavior demonstrated:: Behaviors exhibited this shift. Resident informs nurse that a woman is under her bed and has been using the bathroom under there. How often did this behavior occur/last: 1-3x this shift Describe any interventions attempted:: Redirection and reassured staff nobody was under her bed Effectiveness of Interventions:: somewhat effective 1/4/2025 13:21 *Behavior Note Please describe the behavior demonstrated:: Resident stated to staff when her lunch tray was brought into her room that she couldn't eat it because it was poisoned by the man, she had made angry. How often did this behavior occur/last: 1-2 minutes Describe any interventions attempted:: re-directed resident. Reassured resident that the only people that had access to her tray was the kitchen staff and the CNA that brought in the tray. Effectiveness of Interventions:: somewhat effective 01/3/25 10:18 *Behavior Note Please describe the behavior demonstrated: Entered residents' room to administer residents AM medication. Resident was visibly upset crying. This nurse asked resident if she was okay. Resident stated, No my brother is having sex with a man. During breakfast tray pass resident stated to CNA don't hug me I'm contaminated. Another CNA entered resident's room to asked resident about her shower. Resident stated, I don't think I can take one I'm contaminated and no one needs to be around me. How often did this behavior occur/last: multiple times during a 4-hour period. Describe any interventions attempted:: Re-directed resident. Reassured resident that she wasn't contaminated. Effectiveness of Interventions:: somewhat effective 12/26/24 01:06 *Behavior Note Please describe the behavior demonstrated:: Resident found in bathroom in W/C Resident stated that she was hiding from one of the nurses because she was trying to kill her because she thought that the resident was trying to have sex with her husband and (name) How often did this behavior occur/last: once noted by CNA and once noted by this nurse Describe any interventions attempted:: Attempted to be redirected by Nurse. Effectiveness of Interventions:: Slightly Effective. 11/27/24 22:52 *Behavior Note Please describe the behavior demonstrated:: Resident cont to have dilutions. Stating that Certain peopl are Tring to poison her and that she has to test her food be fore she can eat it. How often did this behavior occur/last: Various times Describe any interventions attempted:: Staff talked to resident. Effectiveness of Interventions:: non-effective 11/25/24 15:35 *Behavior Note Please describe the behavior demonstrated:: Resident sitting in her WC in the hallway. When nurse approached her to give ordered medication she whispered, my baby is in the hospital because the bad man and his wife raped her I know I seen the blood everywhere. How often did this behavior occur/last: 1x this shift Describe any interventions attempted:: Resident redirected; snack provided Effectiveness of Interventions:: somewhat effective 11/24/2024 23:15 *Behavior Note Please describe the behavior demonstrated:: Resident telling nurse that her roommate has died because she was raped by the witch man and his wife after the withch man sucked her viginia out, placed it on a napkin and threw it in the trash to get rid of evidence. How often did this behavior occur/last: x3 Describe any interventions attempted:: Talked to resident Effectiveness of Interventions:: non-effective. 11/23/24 15:25 *Behavior Note Please describe the behavior demonstrated:: CNA entered resident's room on snack pass and resident stated, My roommate is in the hospital because a group of witches came into our room and sucked her (XXX) off. How often did this behavior occur/last: 1x Describe any interventions attempted:: redirection Effectiveness of Interventions:: somewhat effective 11/23/24 13:39 *Behavior Note Please describe the behavior demonstrated:: Resident stated that men keep putting something in my coffee so I can't drink coffee anymore The men are trying to kill me. How often did this behavior occur/last: during meals and snack passes. Describe any interventions attempted:: reassured resident that the only people pouring her coffee was staff and that they bring it directly into her room. Effectiveness of Interventions:: somewhat effective. 11/22/24 22:47 *Behavior Note Please describe the behavior demonstrated:: Resident cont. to have dilutions of people outside of her window waiting to sneak in and sexually assault her. Resident stated that the man with the crooked arm has already sexually assaulted all the other women in the room. How often did this behavior occur/last: Various Describe any interventions attempted:: Resident comforted and made sure that she was safe that no one was going to come in and sexually assault her. Effectiveness of Interventions:: Non-Effective. 11/19/24 21:54 *Behavior Note Please describe the behavior demonstrated:: resident stated to this nurse a story that a man was after her, and today she seen that man in the parking lot with her daughter today having sex with her. How often did this behavior occur/last: once Describe any interventions attempted:: explained to resident that there was no man in the parking lot and she was in a safe place Effectiveness of Interventions:: resident just smiled and said some of them mix up love with sex 11/17/24 15:50 *Behavior Note Please describe the behavior demonstrated:: This nurse was standing in the hallway and observed resident hollering help me. When nurse approached resident's bedside she stated, he's here messing with my oxygen, he's under my bed. How often did this behavior occur/last: 2x this shift Describe any interventions attempted:: Resident redirected and conversation was changed, assured resident of safety, snacks provided Effectiveness of Interventions:: effective at the time staff was in her room, but after staff exited room resident could be heard conversing with herself in her room 11/14/24 22:08 *Behavior Note Please describe the behavior demonstrated:: Resident was noted to state that an employee went to North Carolina Stole and stole her double Agitator Washing Machine. He Then came back and shot everyone in her family with a big ole gun. including her, her Daughter, her daughters husband, Her sister,Her sister's husband. Her Granddaughter, Her Granddaughter's husband, and her Great-grandchild. How often did this behavior occur/last: Serveral times. Describe any interventions attempted:: Attempted to re-orient resident. Effectiveness of Interventions:: Non-effective. 11/11/24 15:04 *Behavior Note Please describe the behavior demonstrated:: Multiple episodes of behaviors exhibited this shift; resident stating staff is poisoning food, her sister has brought her pop and somebody stole it, people are hiding under her bed. How often did this behavior occur/last: multiple episodes throughout shift Describe any interventions attempted:: redirection Effectiveness of Interventions:: somewhat effective at the time behavior is exhibited 11/11/24 16:19 *Behavior Note Please describe the behavior demonstrated:: Resident told evening shift CNA, that [Nurse Aide name] was standing outside her window and killed his wife and said if she won't let him fuck her alive then he will fuck her dead How often did this behavior occur/last: 5 minutes Describe any interventions attempted:: Redirection, resident brought out of her room and in hallway with staff Effectiveness of Interventions:: ineffective 11/9/24 12:35 *Behavior Note Please describe the behavior demonstrated:: Resident going between talking with someone outside of her window and crying. Resident stated, That damn man out there won't leave me alone and he has thrown all my belongings out the window of the 4th floor. How often did this behavior occur/last: on and off during shift thus far. Describe any interventions attempted:: attempted to redirect. Offered reassurance that belongings are safe and that man is no longer outside of window. Effectiveness of Interventions:: somewhat effective 11/7/24 15:13 *Behavior Note Please describe the behavior demonstrated:: Resident continues with behaviors, has been observed emotional and crying at times when nurse approaches room, informs nurse that the people outside her window told her that her daughter has passed away. How often did this behavior occur/last: multiple times this shift Describe any interventions attempted:: staff has sat with resident and attempted redirection from paranoid thoughts Effectiveness of Interventions:: ineffective 11/5/24 12:12 *Behavior Note Please describe the behavior demonstrated:: Resident continues with behaviors. Informs staff that ex-husband is taking her belongings and giving them to other residents. How often did this behavior occur/last: multiple episodes thus far Describe any interventions attempted:: Resident redirected Effectiveness of Interventions:: not effective. 11/4/24 18:36 *Behavior Note Please describe the behavior demonstrated:: Resident continue to have repetitive delusions. How often did this behavior occur/last: often throughout shift. Describe any interventions attempted:: Reassured Resident of her safety Effectiveness of Interventions:: ineffective 10/30/24 23:26 *Behavior Note Please describe the behavior demonstrated:: resident shushed nurse by putting a finger to her mouth and then explained in a very low voice I have her trapped under my bed, you can't raise my bed then resident positioned herself in a almost sitting position to take her medications. How often did this behavior occur/last: once so far Describe any interventions attempted:: redirected resident as much as possible Effectiveness of Interventions:: didn't seem to be effective 10/30/24 13:42 *Behavior Note Please describe the behavior demonstrated:: Resident stated to staff that the Cops won't even come to help me anymore, they just come up here because they want to fuck me. How often did this behavior occur/last: Various times thus far this shift Describe any interventions attempted:: Resident reassured of her personal safety here at this facility Effectiveness of Interventions: 10/29/24 17:52 *Behavior Note Please describe the behavior demonstrated:: Resident continues to experience delusions How often did this behavior occur/last: throughout shift Describe any interventions attempted:: reassured Resident of safety Effectiveness of Interventions:: ineffective 10/28/24 08:00 *Nursing Note Late Entry: Note Text: This Nurse was in Resident's room giving morning medications and talking with Resident. Resident stated, Now you know I love you but you're daughters are doing me dirty, especially the dark haired one. CNA walked in room at this time and was standing beside bed. Resident further stated that the RN supervisor on duty at this time found her old boyfriend (name) from years ago, married him then brought him back here and (xxxxx) him in my bed with me still in it. Resident further stated that afterwards, RN Supervisor and a dayshift CNA crawled under her bed, raised it because it was too low, then stabbed her in the back with knives until the bed was full of blood. Resident stated she had witnesses as there were people watching through the window the whole time. Attempts to redirect Resident were not appropriate at that time due to Resident's agitation. This Nurse reassured Resident she was safe and that we were going to have a good day. Resident was pleasant and agreeable and made no further such statements throughout rest of shift. 10/16/24 06:11 *Behavior Note Please describe the behavior demonstrated:: CNAs was doing ice pitchers when resident asked the CNA in her room if she was another resident and that CNA said no, resident said good cause I want to kill him. And CNA asked her why and she stated that he does not take good care of her. How often did this behavior occur/last: lasted a few minutes Describe any interventions attempted:: explained to resident that CNA takes good care of her Effectiveness of Interventions:: little effectiveness 10/8/24 00:27 *Behavior Note Please describe the behavior demonstrated:: Resident came to nurses desk telling Nursing staff that the house Doctor was in love with her and that he was going to take her out of this place. She stated that he said he would sneak her out the window if he had too but he was taking her out of place.She stated that her daughter was scared of him so she thinks her daughter would just let him take her. How often did this behavior occur/last: x1 just now. Describe any interventions attempted:: Nurse Talked to resident and insured her that she was safe. That no one could take her out of the window. CNA showed Resident that the window was safe. Effectiveness of Interventions:: Resident still cont. to worry but is at much more ease. At approximately 11:03 AM on 01/14/25, an interview was conducted with Licensed Practical Nurse (LPN) #75 regarding the behaviors exhibited by Resident #19. LPN #75 was asked how the staff approach Resident #19 when she exhibits behaviors and what they attempt to do in those situations. LPN #75 stated she will attempt to redirect Resident #19 and, if that is not effective, she will notify the doctor and let them know redirection was not successful. LPN #75 was asked if any other interventions were attempted when redirection was unsuccessful and she stated No. At approximately 11:10 AM on 01/14/25, and interview was conducted with LPN #31 regarding Resident #19's behaviors. LPN #31 stated she will attempt to redirect the resident by talking about her daughter and granddaughter. LPN #31 stated if that does not work, she will put the resident on the doctor's list for increased behaviors when he comes in again. LPN #31 was asked if any additional interventions were attempted if redirection was unsuccessful, to which she stated No. At approximately 1:00 PM on 01/14/25, the Director of Nursing (DON) acknowledged in an interview that no additional non-pharmacological interventions when redirection was unsuccessful, despite the resident having an order for eight (8) interventions.

Based on record review and staff interview, the facility failed to monitor Resident #53 for psychotropic medication side effects in November of 2024, during which time, the resident had an unwitnessed fall. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 53. Facility census: 58. Findings included: a) Resident #53 Resident #53's medical record review revealed she received Remeron and Zyprexa. Resident #53 discovered the resident suffered an unwitnessed fall on 11/01/24. The following note for the fall is typed as written in the progress notes in the resident's medical record: 11/1/2024 16:39 *Nursing Note Note Text: This nurse was walking by in the hallway and observed resident sitting in the floor on her buttocks beside her bed with WC behind her. Appears that resident was trying to self transfer into bed. Residents roommate was standing beside her. When nurse asked resident she stated I don't know what I did. Resident was assisted up and back to WC per her request by 2x staff members. Body evaluation completed and no injuries observed. VS; 104/76, 81, 98.3, 94% off RA, 20. Resident denies any CO pain and is self propelling via WC in hallway. Neuro checks initiated, WC alarm put in place, therapy referral made, and educated resident on the importance of using call light for assistance. FNP notified. VM was left with MPOA to return the call at earliest convenience. Upon further review, it was determined there was no psychotropic side effect monitoring taking place during the month of November 2024. Psychotropic medication side effect monitoring was also missing for the month of December 2024, and was not started until January 2025. At approximately 12:00 PM on 01/15/25 during an interview with the Director of Nursing (DON), she acknowledged side effect monitoring did not take place.

Based on record review, observation, and resident and staff interview, the facility failed to accommodate Resident #36's food preferences by serving her eggs. This was a random opportunity for discovery. Resident identifier: #36. Facility census: 58. Findings included: a) Resident #36 At approximately 2:15 PM on 01/07/25, during an interview with Resident #36, she stated They send me eggs every morning and I can't eat them because I'm allergic to them. The resident reiterated she did not like eggs. At approximately 2:00 PM on 01/08/25, during review of Resident #36's dietary profile dated 12/27/2024, it was noted, under the food allergy section of the assessment, the resident was allergic to eggs. At approximately 8:00 AM on 01/09/25, during observation of the breakfast tray pass, Resident #36 was served a breakfast casserole. At approximately 8:05 AM on 01/09/25, the Dietary Manager (DM) confirmed the breakfast casserole contained eggs. At approximately 8:15 AM the Director of Nursing (DON) confirmed the resident had received breakfast casserole. At approximately 12:00 PM on 01/09/25, the DM provided the survey team with the recipe for the breakfast casserole. The recipe confirms the presence of eggs in the casserole. The facility was able to provide documentation in support of Resident #36 not having an allergy to eggs, however, it was noted the resident voiced her dislike of eggs and did not wish to receive them on her tray.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records for two (4) of 21 residents in the long-term care survey sample. Resident #49 had an incomplete Physician Orders for Scope of Treatment (POST) form. Resident #6 had an inaccurate medication order and care plan. Resident identifiers: #49, and #6. Facility census: 58. Findings included: a) Resident #49 Review of Resident #49's medical records showed a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form completed on 05/24/24. The portion of the POST form regarding medically assisted nutrition was blank. This section contained the following four (4) options: - Provide feeding through new or existing surgically-placed tubes. - Time-limited trial of ____ days but no surgically-placed tubes. - No artificial means of nutrition desired. - Discussed but no decision made (provide standard of care). On 01/08/25 at 12:06 PM, the Director of Nursing (DON) stated medically assisted nutrition was discussed with the resident representative who was unable to make a decision regarding the matter at the time. The DON acknowledged the option Discussed but no decision made (provide standard of care) should have been chosen. Additionally, telephone consent was obtained from the resident's representative on 05/24/24, with two (2) staff members signing to verify the consent. According to the manual titled Using the POST Form Guidance for Healthcare Professionals, available on-line, If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. On 01/15/25 at 12:05 PM, the DON confirmed Resident #49's POST form had not been signed by the resident's representative after verbal consent was obtained. No further information was provided through the completion of the survey process. b) Resident #6 Review of Resident #6's medical records showed an order written on 01/03/25 for Seroquel (quetiapine fumarate) 25 mg at bedtime for dementia with psychosis related to unspecified psychosis not due to a substance or known physical condition. Review of Resident #6's comprehensive care plan showed the following focus initiated on 12/06/24, The resident has risk for complications related to cognitive impairment secondary to dementia, secondary to memory impairment. Review of Resident #6's diagnoses list did not show a diagnosis of dementia. The resident did have a diagnosis of unspecified psychosis not due to a substance or known physical condition. The nurses progress notes documented hallucinations and delusions. The resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 01/01/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. On 01/09/25 at 12:18 PM, the Director of Nursing (DON) stated Resident #6 did not have a diagnosis of dementia. She stated the resident was receiving Seroquel due to psychosis and acknowledged the diagnosis of dementia was incorrect in the order. She also acknowledged the care plan incorrectly stated the resident had a diagnosis of dementia. No further information was provided through the completion of the survey process.

Based on resident interview, medical record review, staff interview and Resident Council Meeting discussion, the facility failed to ensure the resident shower room was at a comfortable temperature for resident use. This failed practice had the potential to affect more than a limited number of residents. Resident Census: 58. Findings Included: a) Resident Shower Room During an interview with Resident #26 on 01/07/25 at 11:39 AM, he stated he refused a shower the day before because the shower room was too cold. He stated one shower room was being renovated, and the other room is always too cold. A review of Resident #13's medical record on 01/07/25 found a nurses note dated 01/04/25 at 2:51 AM which read, Resident refused shower states that it is too cold, and the shower room is cold resident asked again at a later time educated on importance of self-care, On 01/15/24 at 10:30 AM the maintenance director was asked to obtain the temperature in the shower room the temperature at this time was 63.8 degree Fahrenheit (F). The shower room was noted to have two (2) heaters on the wall. The maintenance director stated that he can control them by using the app on his phone or they can be controlled manually as well. He showed the surveyor that the temperatures were set to 72 degrees F. He stated we have ordered new heaters. This shower room was recently remodeled, and the heaters installed were not as robust as they need to be and are not efficient. The Nursing Home Administrator added, The staff come in here and turn on the hot water and get it steamy before they bring the residents in. b) Resident Council Meeting On 01/08/24 at 10:08 AM during the resident council meeting Residents #16, #49, #26, #27, #30 stated that the shower room is very cold. Sometimes they will not take a shower because it is cold. Resident #30 states even Nurse Aides (NA) will make comments about the shower room being cold.

Based on record review and interviews, the facility failed to revise care plan for Resident #40 for one (1) on one (1) activities and Resident #19 and Resident #29 for behaviors. This failed practice was found true for three (3) of 21 residents reviewed for the care planning care area. Resident identifiers: #40, #19, and #29. Facility census: 58. Findings included: a) Resident #40 Record review completed on 01/08/25 revealed resident #40 to be care planned to receive one (1) on one (1) visits from the Activity Department. Further record review on 01/08/25 shows no evidence Resident #40 received one (1) on one (1) visits from the activity department. During an interview with the Activity Director (AD) on 01/09/25 at approximately 2:00 PM, the AD stated We used to do one (1) on one (1) visits, however she (Resident #40) became more independent with activities of her (Resident #40) choice, I'll (AD) update the care plan. Confirming the care plan should have been updated when Resident #40 no longer required one (1) on one (1) visits. b) Resident #19 At approximately 10:00 AM on 01/09/25, during a review of Resident #19's record, it was noted her care plan had a focus for behaviors. The care plan reads as follows: Focus- BEHAVIORS: the resident has behaviors of delusions: fixed false beliefs despite evidence that they are untrue, hallucinations: visual, auditory or other, often makes false allegations, often talks about people wanting to have inappropriate behaviors with her. Date initiated: 11/28/2024 Revision on: 01/08/2025. Goal- The resident's behaviors will cause them less distress thru the review period. Date Initiated: 11/28/2024. Target Date: 04/06/2025. Interventions: -administer medications as ordered. Date initiated: 11/28/2024. -Approach with a calm quiet voice, divert attention, and remove from the situation and take to an alternative location as needed. Date initiated: 11/28/2024. -Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situations. Date initiated: 11/28/2024. During review of notes for psych visits for Resident #19, the following was noted from the consult notes: -Ex-husband was physically abusive. -Patient states she has a bad temper due to men coming and looking into her window and hiding under her bed. Patient states she does not have a good appetite due to believing that people are putting things in her food and drinks to poison her. During a review of Resident #19's orders, it was noted the resident had an order, beginning on 12/30/24, for behavior monitoring and, included in the order, were eight (8) non-pharmacological interventions. The interventions are as follows: (1) Redirect (2) 1:1 (3) activities (4) toilet (5) give food or fluids (6) reposition (7) back rub (8) other-chart in progress notes. Upon further review of Resident #19's care plan, it was discovered the care plan had not been updated to include the non-pharmacological interventions. At approximately 1:10 PM on 01/14/2025, during an interview with the Director of Nursing (DON), it was acknowledged the resident's care plan was not updated to reflect the the non-pharmacological interventions. c) Resident #29 During the initial interview on 01/07/25 at 1:35 PM, Resident #29 stated, I am afraid of the lift. I don't like being in it. They put me in it on shower days. I fell with one of the lifts one time. Now I am afraid. A record review on 01/08/24 at 11:00 AM, of the Brief Interview for Mental Status (BIMS) completed on 10/28/24, revealed that Resident #29 has a BIMS score of 15. Further record review of the care plan for Resident #29 revealed no interventions or behaviors noted related to lift transfers on shower days. During an interview on 01/09/25 at 11:30 AM, Nursing Assistant (NA) #68 stated, She cries and hollers in the lift for showers. When we put her on the shower chair she calms down and then screams and hollers when we put her back in the lift to put her back in bed. During an interview on 01/09/25 at 12:05 PM, NA #47 stated, She screams and cries in the lift. She is scared. During an interview on 01/09/25 at 12:30 PM, Licensed Practical Nurse (LPN) # 75 stated, She screams when it is shower day. I am not sure what it is related to. During an interview on 01/09/25 at 12:40 PM, Registered Nurse Supervisor (RNS) # 45 stated, I can hear her sometimes hollering when she is in the lift. They have not tried anything different with her since I have been here. I have been here for 3 months. During an interview on 01/09/25 at 12:42 PM, The Director of Nursing (DON) stated, I was not aware of the situation. I will check into it and get back to you. During an interview on 01/09/25 at 12:46 PM, Resident #29 stated, I would rather take bed baths if it meant I did not have to get up in the lift. I am afraid of being in it. A record review on 01/09/25 at 1:30 PM, revealed a Behavior Observation Monthly Summary dated 10/06/2024, under B {Behaviors and Side Effects}, question (1) one {Behaviors that triggered psychoactive use/non-pharmacological interventions}, Resident #29 is marked for the following behaviors: cursing, Resists Activities of Daily Living (ADL) care, screaming, crying, Anxiety/agitation, and grabbing. Under question 1a reads as follows: Resident has episodes of refusing care, becoming anxious before ADLs are performed. Further record review revealed, (3) more Behavior Observation Monthly Summary dated 11/06/24, 12/06/24, and 01/07/25, under B {Behaviors and Side Effects}, question (1) one {Behaviors that triggered psychoactive use/non-pharmacological interventions}, Resident #29 is marked for the following behaviors: cursing, Resists Activities of Daily Living (ADL) care, screaming, crying, Anxiety/agitation, and grabbing. A record review on 01/09/25 at 1:45 PM, of the shower task for Resident #29 for the months of 10/2024,11/2024, and 12/2024 revealed that Resident #29 was to have showers on Sunday day shift, and Wednesday evening shift. Within the (3) three month time period Resident #29 had 23 showers documented. Further record review revealed that no interventions have been put in place to minimize the emotional distress with the mechanical lift and that Resident #29 has diagnoses that include Mild Intellectual Disabilities, Cognitive Communication Deficit, Major Depressive Disorder, and Anxiety Disorder. During an interview on 01/09/25 at 2:00 PM, The DON confirmed that no interventions were in place to address the behaviors related to the lift transfers.

Based on record review and interviews, the facility failed to ensure residents were provided activities of interests that he/she was care planned for. This was found true for one (1) of six (6) residents reviewed for the activities care area. Resident identifier: #40. Facility census: 58. Findings included: a) Resident #40 Record review completed on 01/08/25 revealed Resident #40 was care planned to receive one (1) on one (1) visits from the Activity Department. Further record review on 01/08/25 shows no evidence for Resident #40 to receive one (1) on one (1) visits from the activity department. During an interview with the Activity Director (AD) on 01/09/25 at approximately 2:00 PM the AD stated, We used to do one (1) on one (1) visits, however she (Resident #40) became more independent with activities of her choice. I'll update the care plan. Confirming the care plan should have been updated when Resident #40 no longer required one (1) on one (1) visits.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of 21 residents in the long-term care survey sample. Physician's orders to obtain weights were not followed for Resident #26 and Resident #19. Insulin was held without physician orders or notification for Resident #32. Neurological checks were not completed after an unwitnessed fall for Resident #53. Resident identifiers: #26, #32, #53, and #19. Facility census: 58. Findings included: a) Resident #26 Resident #26 had an order written on 08/01/24 for monthly weights. The provider was to be notified if the resident's weight changed more than five (5) pounds. The resident's last weight was recorded on 10/01/24. Resident #26's treatment administration record (TAR) had an area for the nurses to indicate the resident's weight had been obtained. The resident's TAR for November 2024 indicated the resident's weight had been obtained. However, no weight was recorded in the medical record. The resident's TAR for December 2024 had the notation 9 which, according to the chart codes, indicated a nurses note had been written. A nurses note written on 01/01/25 indicated the resident had refused to be weighed. The resident's TAR for January 2025 indicated the resident's weight had been obtained. However, no weight was recorded in the medical record. On 01/15/25 at 4:00 PM, the Director of Nursing (DON) confirmed Resident #26's weight was not recorded for November 2024 and January 2025. She also confirmed no weight refusals were documented for those months. b) Resident #32 Review of Resident #32's physician's orders showed the following orders written on 10/16/23: - Insulin glargine 100 unit/ml (milliliters) inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy, unspecified. - Insulin aspart 100 unit/ml inject 10 unit subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy. Give 10 units for blood sugar greater than 160. Glargine insulin is a long-acting insulin and aspart insulin is a fast-acting insulin. Review of Resident #32's Medication Administration Record (MAR) for January 2025 showed the resident's bedtime insulin had been held on the following dates: - 01/01/25, when the resident's blood glucose was 101. - 01/02/25, when the resident's blood glucose was 97. - 01/05/25, when the resident's blood glucose was 152. Resident #32's medical records showed no communication with the physician regarding holding the insulin. The medical records showed no physician's orders to hold the insulin. On 01/13/25 at 2:45 PM, the Director of Nursing (DON) acknowledged Resident #32's bedtime insulin had been held without physician's orders to do so. No further information was provided through the completion of the survey c) Resident #53 At approximately 1:00 PM on 01/08/2025, during a review of Resident #53's record, it was determined the resident had an unwitnessed fall on 11/01/24. The following note for the fall is typed as written in the progress notes in the resident's medical record: 11/01/24 16:39 *Nursing Note Note Text: This nurse was walking by in the hallway and observed resident sitting in the floor on her buttocks beside her bed with WC (wheelchair) behind her. Appears that resident was trying to self transfer into bed. Residents roommate was standing beside her. When nurse asked resident she stated I don't know what I did. Resident was assisted up and back to WC per her request by 2x staff members. Body evaluation completed and no injuries observed. VS; 104/76, 81, 98.3, 94% off RA, 20. Resident denies any CO pain and is self propelling via WC in hallway. Neuro checks initiated, WC alarm put in place, therapy referral made, and educated resident on the importance of using call light for assistance. FNP notified. VM was left with MPOA to return the call at earliest convenience. Upon review of the neuro checks with the effective date of 11/01/24, it was determined the facility did not complete the second, third, and fourth four (4) hour check, as the assessments were not signed off on. At approximately 2:20 PM on 01/15/25 during an interview with the Director of Nursing (DON), the neurological checks were confirmed to be incomplete. d) Resident #19 During a review of Resident #19's orders on 01/13/25, it was discovered that the resident had orders for weekly weights. The order reads as follows: Weekly weights x4 weeks every day shift every Monday for monitoring for 4 weeks. This order was to start on 12/23/24 and end on 01/20/25. Upon review of the resident's weights, it was determined no weight had been taken the week of 01/05/25 through 01/11/25. One weight was obtained on 01/01/25, with the next one being obtained on 01/13/25. At approximately 1:00 PM on 01/14/25, the Director of Nursing (DON) confirmed the weight missing from the week of 01/05/25-01/11/25.

Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A storage room containing hazardous items was found to be unlocked. This was a random opportunity for discovery that had the potential to affect any resident able to access the closet. Facility census: 58. Findings included: a) Storage room On 01/07/25 at 11:04 AM, a door with signage stating ''new linen room was found to be able to be opened by the surveyor. The door had a keypad on it. In addition to containing clean linens, the room had toiletries, including razor blades. On 01/07/25 at 11:06 AM, Licensed Practical Nurse (LPN) #31 confirmed the door was unlocked. She acknowledged the door should have been locked. It was found that the door did not close easily and remained unlocked unless the door was forcefully closed. When the door was forcefully closed, it did lock. LPN #31 stated she would have maintenance fix the door. No further information was provided through the completion of the survey.

Based on record review, staff interview and policy review, the facility failed to ensure a licensed pharmacist completed a monthly drug regimen review, reported any irregularities to the attending physician and the attending physician responded to any recommendations within the time frame established by the facility policy. This was true for three (3) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident Identifiers: #30, #53, and #32. Facility Census: 58. Findings Included: a) Resident #30 A review of Resident #30's medical record on the morning of 01/13/25 found no evidence that the pharmacist had reviewed Resident #30's drug regimen in the months of 08/2024, 09/2024, and 10/2024. In an interview with the Director of Nursing (DON) on 01/13/25 at 3:00 PM she confirmed she could not find any evidence to show the licensed pharmacist had reviewed Resident #30's drug regimen on the above mentioned months. b) Resident #53 At approximately 1:00 PM on 01/08/2024, during a review of Resident #53's medical record, it was determined the facility was missing a pharmacy recommendation and physician's response for the month of November 2024. During review, a pharmacy recommendation dated for 12/26/2024 states The recommendation dated 11/25/24 (the missing recommendation) for nursing on behavior monitoring does not have a response in the chart. At approximately 12:00 PM on 01/15/2025 during an interview with the Director of Nursing (DON), she acknowledged the absence of the November 2024 pharmacy recommendation and physician's response. c) Resident #32 Review of Resident #32's medical records showed a Consultant Pharmacist Recommendation to Physician from a Medication Regimen Review (MRR) dated 04/30/24. The recommendation stated, This resident has been taking escitalopram [Lexapro] 10 mg [milligrams] qd [every day] since 10/2023 without a GDR [gradual dose reduction]. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. The physician response was Change therapy as follows: escitalopram 10 - 5 mg. The form was signed by the resident's physician, who was also the facility's medical director, on 06/27/24. The next Consultant Pharmacist Recommendation to Physician was from a Medication Regimen Review (MRR) dated 05/31/24. The recommendation stated, This resident has been taking lorazepam 0.25 mg QOD [every other day] since 12/2023 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. The physician response was GDR lexapro, hold off until next review. The form was signed by the physician on 06/27/24. On 01/13/25 at 2:40 PM, the Director of Nursing confirmed the physician did not respond to Resident #32's Consultant Pharmacist Recommendation dated 04/30/24 within the 30 days prescribed by the facility's policy. She acknowledged the physician responded to the recommendations from 04/30/24 and 05/31/24 on the same day. No further information was provided through the completion of the survey. d) Policy Review The facility's policy titled Medication Regimen Review, with no implementation or revision dates, stated as follows: - The consulting pharmacist would perform monthly medication regimen reviews for every resident in the facility - The consulting pharmacist would provide copy of recommendations to the attending physician, medical director, and director of nursing within five (5) working days of completion of the review. - If the attending physician did not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to ensure food was served at a palatable temperature. This failed practice had the potential to affect more than an limited number of residents. Facility Census: 58. Findings Included: a) Grievance review A review of the grievances found the following grievances noted: Resident #13 and Resident #15, filed a grievance dated 03/22/24. The Residents stated the food is cool and they are not using the plate warmer. Resident #11 filed a grievance dated 08/21/24 and stated, when her tray is delivered it is cold almost every time at dinner time. Resident #1 filed a grievance dated 11/20/24 the resident indicated the pancakes were cold, not enough sausage, and the pancake was so hard she could not cut it. b) Resident Interviews On 01/07/25 at 11:38 AM, Resident #26 stated his food was often cold when served to him. On 01/07/25 at 2:26 PM, Resident #7 stated her food, especially soup, was often cold when served to her. During and interview with Resident #13 on 01/07/25 at 12:22 PM, the resident stated the food looks bad and it is cold all the time and the meat is tough. c) Food temperature Measurement On 01/08/25 at 12:08 PM the Dietary manager obtained the temperature of the meal items served during the noon time meal. The temperatures were obtained when the final resident received their meal tray. The following temperatures were obtained: --Chicken Strip: 101.1 degrees Fahrenheit -- [NAME] Slaw: 54.3 degrees Fahrenheit. The Dietary Manager stated she was going to take the temperature of the other chicken strip. She obtained the temperature the surveyor noted the temperature was 100 degrees F. The dietary manager in an interview later in the day on 01/08/25 stated she thought the temperature of the second chicken tender was 131 degrees. The surveyor and the Dietary manager was unable to agree on the temperature of the second tender however we did agree on the temperature of the first tender which as 101.1 degrees F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and and staff interview, the facility failed to ensure food was stored and an served in a safe and sanitary manner. There were multiple items in the walk-in cooler that was either out of date or not dated to indicate when they had been opened. Additionally two (2) vents in the kitchen ceiling had a collection of dust around the vents on the ceiling. The vent on the HVAC unit in the kitchen had a collection of dust on the outer metal grate covering the filter. The filter itself was also completely covered in dust. This failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 58. Findings Included: a) Walk in cooler: An initial tour of the kitchen with the Dietary Manager (DM) on 01/07/25 beginning at 10:47 AM found the following food storage issues in the walk in cooler: - 37 individual cups of assorted yogurt which all had a manufactures stamped expiration date of 01/06/25. - A prepackaged container of fruit salad that had an open date of 12/17/24 and a manufactured stamped expiration date of 12/28/24. -- One (1) five (5) pound (LB) bag of shredded cheddar cheese that had a discard date of 01/05/25. - One 46 ounce (oz) container of [NAME] apple sauce which was opened and partially used did not have an open date. - One (1) five (5) LB container of scramble egg mix which was opened and not dated. -- Two (2) five (5) LB bags of mozzarella cheese one was nearly empty and both were opened and not dated. The DM confirmed all findings at the time of discovery and discarded all items. b) Cleanliness Additional observation of the kitchen with the DM on 01/08/25 at approximately 12:15 PM with the DM found a collection of dust around two (2) ceiling vents. The vents themselves were not dusty however the ceiling surrounding the vents was covered in dust. One (1) of the vents was directly over the steam table. Also the the metal grate covering the filter on the HVAC (Heating, Ventilation and air conditioning) unit was covered in dust. The filter under the metal grate was also covered in dust. When asked who was responsible for cleaning identified areas the DM stated it was the responsibility of maintenance. At 12:17 PM on 01/08/25 Maintenance Assistant #55 confirmed the metal grate on the HVAC system needed cleaned. She was was asked how often the filter on the system needed to be replaced, she indicated that it should be done monthly. She said, It should be dated for the day it was last changed. She removed the filter and confirmed there was not a date on the filter and confirmed it needed to be changed. The DM confirmed the areas on the ceiling around the vents also needed to be cleaned.

Based on observation and staff interview, the facility failed to follow proper infection control practices, by dropping cartons of milk on the floor and placing them back in the cart with clean cartons, by sending uncovered cups full of coffee out onto the floor from the kitchen, and by failing to ensure enhanced barrier precautions were followed and posted for Residents #20 and 58. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: 20, 58. Facility census: 58. Findings included: a) Milk cartons At approximately 11:53 AM on 01/07/25 Nurse Aide (NA) #58 was observed, during lunch tray pass, dropping two cartons of milk on the floor. NA #58 picked up the two cartons and placed them back in the cart with the clean milk cartons. NA #58 acknowledged dropping the milk cartons on the floor and returning them to the cart with the clean milk cartons and stated I don't know why I did that, I just wasn't thinking. b) Coffee cups At approximately 11:59 AM on 01/07/25, during lunch tray pass, a tray of approximately 12 cups of coffee was observed on the drink cart, full of coffee, uncovered, with no lids. NA #48 confirmed the cups were sent from the kitchen, filled with coffee, uncovered, with no lids. NA #48 most of the time they are sent out with lids on them but I guess they must have forgotten to put them on today. c) Resident #20 Resident #20 had Enhanced Barrier Precautions (EBP) signage in her room over her bed. On 01/14/25 at 9:21 AM, Licensed Practical Nurse (LPN) #33 donned gloves but not a gown and entered the resident's room to perform a skin check focused to bony prominences. The resident stated she had been having diarrhea. When LPN #33 undid the resident's brief, the resident did have dark soft stool in her brief. LPN #33 was asked why the resident was on EBP. She stated she did not know because she usually worked in the other hallway. The resident had an order written on 09/25/24 for infection precautions - EBP R/T [related to] impaired skin integrity. The resident's progress notes showed the resident had three (3) previous stage II pressure ulcers to her buttocks and coccyx. The last one healed 11/12/24. On 01/14/25 at 11:25 AM, the Director of Nursing (DON) acknowledged a gown should have been worn for skin inspections for residents with Enhanced Barrier signage. d) Resident #58 Resident #58 had Enhanced Barrier Precautions (EBP) signage in her room over her bed. On 01/14/25 at 9:21 AM, Licensed Practical Nurse (LPN) #33 donned gloves but not a gown and entered the resident's room to perform a skin check focused to bony prominences. LPN #33 stated she did not know why the resident was on EBP. In addition to inspecting the resident's bony prominences, LPN #33 had interacted with the resident's bed covers by straightening out the resident's bed covers. Review of the resident's orders showed no orders for Enhanced Barrier Precautions. On 01/14/25 at 11:25 AM, the Director of Nursing (DON) acknowledged a gown should have been worn for skin inspections for residents with Enhanced Barrier signage. e) Policy review The facility's policy titled Enhanced Barrier Precautions (EBP) Policy with original date 03/24/24 stated EBP should be utilized during the following activities: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use - Wound care The facility's Enhanced Barrier Precautions signage stated providers and staff must wear gloves and a gown for the following high-contact resident care activities: - Dressing - Bathing/showering - Transferring - Changing linens - Providing hygiene - Changing briefs or assisting with toileting - Device care or use - Wound care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer pneumococcal vaccines in accordance with Centers for Disease Control (CDC) guidelines. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #6 and #17. Facility census: 58. Findings included: a) Resident # 6 Review of Resident #6's medical records showed the resident signed a consent to have a PPSV23 vaccination administered on 12/06/24. The consent stated PCV20 may be used if PPSV23 was not available. The consent stated, The CDC recommends one pneumococcal vaccine PPSV23 for adults [AGE] years of age or older. If you are 65 or older and have not had a pneumonia vaccine, or received PCV13, PCV15 or PCV20 at least 1 year ago or PPSV23 at least 5 years ago (when under 65), you should receive one dose of PPSV23. On 12/11/24, Resident #6 received vaccination with PPSV23. b) Resident #17 Review of Resident #17's medical records showed the resident's representative signed a consent to have a PPSV23 vaccination administered on 12/12/24. The consent stated PCV20 may be used if PPSV23 was not available. The consent stated, The CDC recommends one pneumococcal vaccine PPSV23 for adults [AGE] years of age or older. If you are 65 or older and have not had a pneumonia vaccine, or received PCV13, PCV15 or PCV20 at least 1 year ago or PPSV23 at least 5 years ago (when under 65), you should receive one dose of PPSV23. On 01/04/25, Resident #6 received vaccination with PPSV23. c) Policy Review The resident's policy titled Pneumococcal Vaccine, with no implementation or revision date given, stated residents would be offered the pneumococcal vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control (CDC) and/or the Advisory Committee on Immunization Practices (ACIP). The ACIP is a committee within the CDC. According to the CDC's guidance regarding pneumococcal vaccine timing for adults dated October 2024, available online, adults 50 years or older who have not received prior pneumococcal vaccines should be offered one of the following: - Pneumococcal 20-valent Conjugate Vaccine (PCV20) - Pneumococcal 20-valent Conjugate Vaccine (PCV21) - Pneumococcal 20-valent Conjugate Vaccine 15 (PCV15) followed by pneumococcal polysaccharide vaccine 23 (PPSC23) after a year d) Interview During an interview on 01/15/25 at 10:00 AM, the Director of Nursing (DON) confirmed unvaccinated residents were offered PPSV23 vaccination and PCV20 was only used when PPSV23 vaccination was unavailable. The DON stated the facility was unaware that CDC guidelines for pneumococcal vaccinations had changed and no longer recommended PPSV23 vaccination for unvaccinated residents.

Based on record review and staff interview, the facility failed to complete an accurate facility assessment related to the overall acuity of care needed for its population. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Extended Survey Process. Facility census 58. Findings Included: a) Facility Assessment (FA) A review on 01/14/24 at 11:30 AM of the Facility Assessment revealed the facility reviewed their FA on 10/24/24. Under over all acuity of residents the following calculations were determined: Assistance with Activities of Daily Living (ADL's) 20 % Mobility impairments 0% incontinence impairments 0% cognitive or behavioral impairment 18.18 % specialized care ( dialysis, vents, wound care) 0 % Other NA During an interview, on 01/14/25 at 2:00 PM, the Administrator stated, I missed a section evidently. I will fix it. He confirmed that he did not feel the overall acuity section out correctly. The Administrator later confirmed that the facility assessment was incorrect. A review on 01/14/24 at 2:20 PM of the tool titled {Simple Long Term Care (LTC) Diagnosis), that the facility used to determine acuity of care from 10/2023 to 10/2024 indicated the following: Diseases of the musculoskeletal system and connective tissue: 64.9% Factors influencing health status and contact with health services: 53.2% Diseases of the Genitourinary system: 51.4% Diseases of the skin and subcutaneous tissue: 26.1% A review on 01/14/24 at 2:30 PM of the Policy titled, Facility Assessment, Under (3) three, C, reads as follows: c. Factors that affect the overall acuity of the residents, such as number and percentages of residents with: i. Need for assistance with ADL s ii. Mobility impairments iii. Incontinence (bowel or bladder) iv. Cognitive, substance use disorder, trauma or behavioral healthcare needs/ impairments v. Conditions or diseases that require specialized care (dialysis, ventilators, wound care).

Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the water management program to reduce Legionella growth and spread in the facility. This practice had the potential to affect all residents that reside in the facility. Facility census: 52. Findings included: a) Water Management Program Review of the facility's water management program found documentation was not maintained to reduce the building's risk for growing and spreading Legionella. The flow diagram did not identify the building's water systems for which Legionella control measures are needed. No documentation was provided describing the building water systems using text and flow diagrams, and no documentation was provided to identify areas where Legionella could grow and spread. No documentation was made on where control measures should be applied and how the control measures would be monitored. On 03/05/24 at 2:20 PM, the Maintenance Director verified the facility did not maintain the water management program. He stated that it would be corrected.

Based on observation and staff interview, the facility failed to promote dignity during dining. Residents were not served lunch trays at the same time as roommates for dining within the residents' room. This was a random opportunity for discovery and had the potential to affect only a limited number of residents. Resident identifiers: #14, #45. Facility census: 55. Findings included: a) On 01/09/24 at 12:08 PM Resident #45 was served a lunch tray in her room and began eating. At 12:14 PM Resident #14 (Resident #45's roommate) was observed ambulating out of the room and grabbed a tray off the tray cart and returned to her room with the lunch tray. Resident #14 set the tray on her bed, removed the plate cover, and began to eat. The surveyor informed Certified Nurse Aide (CNA) #25 the resident had obtained a tray from the tray cart and was eating it. CNA #25 went into Resident #14's room, looked at the meal ticket and removed the tray. CNA #25 stated, That's not even her tray its [Resident #41's first name]. I will get him a new tray. At 12:16 PM, CNA #25 located Resident #14's meal tray and delivered it to her. Resident #14 began eating again. During an interview, on 01/09/24 at 12:45 PM, the Director of Nursing (DON) stated, I was down here [on long hall resident care area] when the trays came out and I left because I didn't want them nervous. I will make sure tray pass goes better at dinner time. The DON further stated, We shouldn't have residents coming out and getting their own trays, we have to work on our process. The DON agreed both residents dining in their rooms should have been served trays at the same time.

Based on observation and staff interview the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature for Resident # 54. This was a random opportunity for discovery. Resident identifier: 54. Facility census: 55. Findings included: a) On 01/09/24 at 12:02 PM, meal trays were transported to the hallway on open food delivery carts. Dietary Manager (DM) manager stated they had enclosed tray carts; however, they were upstairs, and they cannot get them downstairs due to the elevator being currently down. On 01/09/24 at 12.25 pm temperatures were obtained on the lunch meal tray for Resident #54 at the time of service. The following temperatures were obtained by the DM using her thermometer. -- Mashed potatoes with gravy: 125 degrees Fahrenheit (F) - Ham: 122 degrees F --Broccoli: 110 degrees F --Milk: 39 degrees F -Milkshake: 39 degrees F On 01/09/24 at 3:02 PM enclosed tray carts were noted to be available for staff use by the kitchen hallway. On 01/9/24 at 3:06 PM DM stated the carts will be used for the next meal at dinner . On 01/09/24 at 3:30 PM the administrator stated the temperature for broccoli should have been at least 120 F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure residents had access to water that was a comfortable temperature desired by the resident. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: #14. Facility census 49. Findings included: a) Resident #14 On 08/28/23 at 10:35 AM, Resident #14 said she has been at this facility for three (3) years and has not had hot water in her sink the whole time. She went on to say, she gets warm showers but on the days she does not she has to wash up with cold water or wait until one (1) of the Nurse Aides (NA) has time to bring me a pan of warm water. She also said that she would love to wash her hands in warm water and the NA's must use hand sanitizer because of no hot water. On 08/28/23 at 12:00 PM, Maintenance Staff #56 came to check the hot water temperature in room [ROOM NUMBER]. E#56 turned on the hot water in the sink at 12:07 PM, and ran the water until 12:09 PM. The highest temperature was 75.9 degrees. Maintenance # 56 also checked the hot water temperature in room [ROOM NUMBER]. He started the water running at 12:07 PM and checked the temperature at 12:10 PM. The temperature was 75.9 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were offered the pneumococcal immunization recommended by The Centers for Disease Control (CDC). This was true for two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #6, #9. Facility census: 49. Findings included: a) Policy Review The facility's policy titled Pneumococcal Vaccine dated 2001 with revision date 2016 stated that administration of pneumococcal vaccination or revaccinations would be made in accordance with current CDC recommendations at the time of the vaccination. b) Resident #6 Review of Resident #6's medical records showed Resident #6's Medical Power of Attorney (MPOA) was offered the Pneumococcal Polysaccharide Vaccine (PPSV23) vaccination for the resident upon admission [DATE]. The MPOA declined the vaccination. The CDC's publication titled Pneumococcal Vaccine Timing for Adults with implementation date 03/15/23, available on-line, recommended non-vaccinated adults receive Pneumococcal 20-valent Conjugate Vaccine (PCV20) vaccination. During an interview on 8/28/23 at 3:30 PM, the Infection Preventionist confirmed Resident #6's Medical Power of Attorney had not been offered the pneumococcal vaccination PCV20 in accordance with current CDC recommendations. No further information was provided through the completion of the survey. c) Resident #9 Review of Resident #9's records documented upon the resident's admission on [DATE] that the resident had received PPSV23 vaccination in 2019. The CDC's publication titled Pneumococcal Vaccine Timing for Adults with implementation date 03/15/23, available on-line, recommended adults vaccinated with PPSV23 receive PCV20 vaccination one (1) year after the PPSV23 vaccination. During an interview on 8/28/23 at 3:30 PM, the Infection Preventionist confirmed Resident #9 had not been offered PCV20 vaccination in accordance with current CDC recommendations. No further information was provided through the completion of the survey.

Based on observation and staff interview the facility failed to provide Residents on the second floor with a dignified dining experience. Residents were not served meals in the traditional dinnerware. This was a random opportunity for discovery and had the potential to affect all 11 Residents residing on the second floor. Facility Census: 49. Findings Included: a) Observation of Second Floor dining During an Second floor observation on 08/28/23 at 1:02 PM, Nurse Aide (NA) #16 was carrying a tray with a Resident's noon meal. The meal was in a Styrofoam tray, NA #16 stated their meals come in styrofoam along with their drinks and plastic silverware. All the Residents on the second floor that receive meals have them served in styrofoam since the flood on Memorial Day. During an interview on 08/28/23 at 1:25 PM, the Certified Dietary Manager (CDM) stated it was a request of the building for dietary to serve the meals in styrofoam for the second floor residents. The elevator is not working, the staff are carrying the food up the steps. During an interview on 08/28/23 at 3:37 PM, the Administrator stated we are using styrofoam for serving the Residents on the second floor for staff convenience. We had to pack the trays from the kitchen to the second floor and did not want to kill our staff with heavy dishware. We are a 60 bed facility, we only have 49 residents at this time and 11 residents are on the second floor. We don't like to have all the residents on the first floor. I don't want to move the second floor residents downstairs. It feels so cramped down here. They need their own rooms. The Administrator was then asked so you would rather have your staff pack the trays up the stairs and your residents eat from non traditional dinnerware than move them? The Administrator stated, I will not move the Residents from the second floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interview, the facility failed to provide a clean and sanitary environment. This failed practice had the potential to affect all the Residents that receive nourishment from the facility kitchen. The facility also failed to maintain Rooms 129, 130, 131, 132 and the Long Hall in a sanitary condition. Facility Census: 49 Findings Included: a) An in the Kitchen During an initial tour of the kitchen on 08/28/23 at 10:41 AM, with the Certified Dietary Manager (CDM) an observation of an industrial size floor fan was revealed. The fan had an accumulation of dust on the fan blades and a thick layer of a light brown substance around the inside of the fan. The base of the fan had a build up of food particles. During an immediate interview the CDM stated the air conditioner is broken. They are here repairing it today. The CDM was asked, who is responsible for the cleaning of the fan? The CDM stated the Maintenance Department. During an interview on 08/28/23 at 11:15 AM, Maintenance #56 stated we have not cleaned it, and there are no reports on it ever being cleaned. During another observation on 08/28/23 at 1:25 PM, the dirty fan was still in use During an immediate interview the CDM stated when it cools off a little bit more I will get rid of that fan. b) Bathrooms number 129, 131, 130, and 132 During a tour of the facility on 08/28/23 at 10:39 AM, the bathroom shared by room [ROOM NUMBER] and 131, had a foul odor, and a heavy build up of a brown substance around the bottom of the toilet. The light cover on the ceiling was full of what appeared to be insects. The bathroom shared between rooms [ROOM NUMBERS] also had a heavy build up of a brown substance, had a strong foul odor, and had a dark substance smeared on the outside of the toilet bowl. The overhead light had a large amount of what appeared to be dead insects. On 08/28/23 at 2:33 PM, the above conditions were observed by the Director of Environmental Services (DOES) #63. DOES #65 agreed the bathrooms had a foul odor, were heavily soiled around the toilets, and had soiled overhead light covers that needed cleaned. c) room [ROOM NUMBER] room [ROOM NUMBER] was toured with DOES #65 on 08/28/23 at 2:40 PM, to verify a hole was cut out of the wall under the sink exposing pipes. The countertop around the sink was split and broken, the dresser had a broken drawer hanging down, and the footboard of the bed and the bedside over- the- bed table was peeling and had exposed particle board. d) Long Hall A tour of the Long Hall on 08/28/23 at 2:50 PM, with DOES #65 revealed the vents on the ceiling were covered with a large amount of dust and debris and needed to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . b) Resident room [ROOM NUMBER] On 04/24/23 11:45 AM, the window blind in room [ROOM NUMBER] was found to be tied up with a blue disposable glove and could be pulled only a quarter of the way down. Nurse Aide (NA) #12 stated she has told them [Maintenance staff] about it several times, and it's never been repaired. NA #12 stated, Yes ma'am you can see straight through, and right there is the parking lot, no way to provide privacy. Resident #21 had the privacy curtain pulled over and tacked to the wall covering half the window. There was still approximately a two-foot vertical gap of window that was not covered, and the parking lot was visible. Resident #21 and #50 both resided in the room. On 04/26/23 at 11:43 AM, the Director of Nursing was asked to observe the broken window blind in Resident room [ROOM NUMBER]. The DON stated, My God that's hideous, and you can see straight into the room from the parking lot. The DON further stated she would make sure the window blind was repaired, there was no way the Residents in that room could have any privacy. Based on observation, resident interview, and staff interview, the facility failed to ensure resident privacy was available during the delivery of personal care. Windows were not covered and a resident's room door was not closed during care. These findings were random opportunities for discovery. Resident identifiers: #107, #21, #50 and room [ROOM NUMBER]. Facility census 48. Findings included: a) Resident #107 During an interview with Resident #107 on 04/24/23 at 2:48 PM, Resident #107 said her window blinds don't close all the way. The resident had her privacy curtain pinned across the window. The facility parking lot is just outside the window. a 1) Resident #107 On 04/25/23 at 1:00 PM, Registered Nurse #57 was providing care for Resident #107 and did not close the door. It was noted that a male resident was in the hall looking in the room at Resident #107 while she was uncovered and exposed. RN #57 was asked to close the door. RN #57 said she cannot close the door because she must keep her eye on her treatment cart. With the male resident still standing in the hall looking in, RN #57 was asked again to respect the privacy of Resident #107 and close the door. .

. b) Resident #207 On 04/24/23 at 1:10 PM, during the initial interview phase of the Long Term Care Survey Process, Resident #207 had an isolation caddy and door bag for personal protective equipment (PPE.) Upon confirmation with Licensed Practical Nurse #19 she states the resident was in isolation for Methicillin-resistant Staphylococcus aureus (MRSA). There was no isolation sign on the door indicating what PPE is needed for staff and/or visitors. The resident should have been in contact precautions for MRSA, not standard precautions. This was also confirmed with the Infection Preventist on 04/24/23 at 2:10 PM. Further record review found the facility failed to develop a care plan to reflect the Resident is in contact isolation for MRSA. This was confirmed with the Director of nursing on 04/25/23 at 2:40 PM. Based on Observation, record review and staff interview the facility failed to develop a comprehensive person-centered care plan in the care area of pressure injury preventions, privacy cover on a Foley catheter collection bag, and having a resident placed in contact isolation. This was true for three (3) out of 16 residents reviewed for care plans. Facility census 48. Findings included: a) Resident #107 (treatment and prevention of pressure ulcers) During an observation of pressure ulcer care on 04/25/23 at 1:00 PM, Resident #107 had a Deep Tissue Injury (DTI) on the left heel extending to the outer lateral foot. The wound was deep purple in color, approximately 5.5 cm in length and 4 cm in width. Before the care was provided it was noted that there was no type of pillow or boot being used to keep pressure off the left heel. After the care was completed again the left foot was left lying directly on the mattress. On 04/25/23 at 2:10 PM, Registered Nurse #57 was asked if any interventions were in place to off load the pressure on the left heel to prevent further damage. RN #57 stated there was none. a1) Resident #107 (privacy cover on Foley catheter bag) During an observation on 04/24/23 at 2:47 PM, it was noted Resident #107 had an indwelling Foley catheter. The collection bag was hanging on the left side of the bed without a privacy cover on the collection bag. Licensed Practical Nurse #53 also observed the collection bag. On 04/25/23 at 2:45 PM the Director of Nursing (DON) confirmed the current care plan failed to address interventions for pressure ulcer healing and a privacy cover for a Foley catheter bag. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview and resident interview, the facility failed to hold a care plan meeting and involve R #17 in his individual care planning process. This was true for one (1) of 16 Residents reviewed for care plans. Resident identifier: #17. Facility census: 48. Findings included: a) Resident #17 On 04/24/23 at 12:12 PM, Resident #17 asked the surveyor to find out his plan and how long he was going to have to stay here. The resident stated he has never been to any meetings and had never heard of a care plan meeting. Resident #17 was admitted [DATE]. Record review of progress notes found no mention of a care plan meeting ever being held for Resident #17. During an interview on 04/26/23 at 10:28 AM, the Director of Nursing (DON) stated, I can't say we had a care plan meeting. The DON further explained the social worker left the faciity on 4/12/23, and a letter had been sent out 03/27/23 for a care plan meeting that was to be scheduled on 04/20/23. The DON stated, I have no idea if that meeting happened because no documentation can be found. Record review showed an invitation letter dated 03/27/23 and signed by the previous social worker indicated a care plan meeting for Resident #17 was to take place on 04/20/23. During an interview on 04/27/23 the Administrator stated she was trying to pick up some of the social workers' tasks. The Administrator verified no care plan meetings had been held since the social worker left on 04/12/23. The Administrator stated, I guess I better get that stuff out and take a look at it soon. .

. Based on record review, staff interview and resident interview, the facility failed to provide appropriate care for elevated blood glucose levels for one (1) of one (1) Resident reviewed for unnecessary medications. Resident identifier: #21. Facility census: 48. Findings included: a) Resident #48 During an interview on 04/24/23 at 12:49 PM, Resident #21 stated his blood sugars had been running high. Record review showed the following blood glucose levels to be extremely elevated in April with no documentation of interventions or provider notification: 04/03/23 518 mg/dL at 7:00 AM 04/03/23 518 mg/dL at 5:00 PM 04/07/23 443 mg/dL at 7:00 AM 04/12/23 600 mg/dL at 11:00 AM 04/17/23 501 mg/dL at 7:00 AM 04/17/23 501 mg/dL at 5:00 PM Record review showed the following orders for treatment: Humalog U-100 Insulin (insulin lispro) cartridge; 100 unit/mL; amount: 15 units; subcutaneous Special Instructions: Hold if BS < 160. Once A Day at 11:00 AM. Humalog U-100 Insulin (insulin lispro) cartridge; 100 unit/mL; amount: 5 units; subcutaneous Special Instructions: Hold if blood sugar is less than 140. Once A Day at 07:00 AM. Humalog U-100 Insulin (insulin lispro) solution; 100 unit/mL; amount: 15 units; subcutaneous Special Instructions: Hold for BS less than 160. Once A Day at 05:00 PM. Lantus U-100 Insulin (insulin glargine) solution; 100 unit/mL; amount: 10 units; subcutaneous At Bedtime at 8:00 PM. Accu Checks before meals and at bedtime: 07:00 AM, 11:00 AM, 05:00 PM, 08:00 PM. Review of Lab Results drawn on 04/10/23 at 6:03 AM showed the Resident's A1C level was elevated at 7.1 percent (normal range 4.0-6.0) and Glucose level was 199 mg/dl (normal range 75-109). Record review showed a diagnosis of Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma; and Type 2 diabetes mellitus without complications. During an interview on 04/26/23 at 2:26 PM, the Director of Nursing (DON) stated that the physician should have been notified regarding the elevated blood sugars. The DON said, That is just nursing standard of care, they should have called the doctor and documented what they [nursing staff] did for the high blood sugars. But I have nothing, not one note. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview the facility failed to ensure residents receive care, consistent with professional standards of practice, for care of pressure ulcers. This was true for one (1) of one (1) resident reviewed for pressure ulcer care. Resident identifiers: Resident identifier: # 107. Facility census 48. Findings included: a) Resident #107 A review of the medical records revealed Resident # 107 was admitted to the facility on [DATE]. Resident # 107 was noted to have pressure injuries on the left heel, left and right thigh, sacrum, and left buttock. An observation of pressure ulcer care on 04/25/23 at 1:00 PM, with Registered Nurse #57, found the following: RN #57 failed to clear, disinfect and use a side table to place the supplies on for the pressure ulcer care. RN #57 used a single paper towel and placed it on the foot of the bed, she then put the supplies on the paper towel. The sheets on the bed had red blood smears and visible brown debris on them. RN #57 carried the can of wound cleanser in the room and laid it on the bed. The can fell to the floor, RN #57 placed the can under her right arm and then placed the can back on the bed. When RN#57 went back to the treatment cart for more supplies. RN #57 placed the can of wound cleanser on the counter next to the sink. Once again RN#57 placed a paper towel on the soiled bed sheets. When staff were helping RN #57 roll Resident # 107 over for the pressure ulcer care, Resident # 107's left foot fell on top of the paper towel and the dressing supplies, knocking the wound care supplies directly onto the soiled sheets. RN #57 tossed a box of Medihoney (used for pressure injury wounds to promote healing) on the bed bedside of the paper towel. RN #57 returned the used tube of Medihoney to the treatment cart. After the dressings were replaced, RN #57 placed the can of wound cleanser on top of the treatment cart and told Licensed Practical Nurse #53 to put it back in the treatment cart. On 04/06/23 at 2:10 PM, after RN #57 was finished with the dressing changes, she was asked about clearing the side table, using a disinfectant, and placing a barrier on the side table with the supplies. RN #57 stated, the state makes her nervous and she knew she made many mistakes. On 04/25/23 at 2:45 PM the Director of Nursing (DON) was informed of the above information. .

. Based on observation, record review and staff interview the facility failed to ensure the environment is free from accident hazards. This was true for one (1) of one (1) resident reviewed for the care area of accidents related to smoking and one (1) was a random act of discovery. Resident identifiers: #11 and #3. Facility Census: #48 Findings Included: a) Resident #11 On 04/24/23 at 2:55 PM records revealed Resident #11 is a smoker. Further record review found the following: 06/15/22 Quarterly Tobacco Use Observation assessment, Description: Annual Assessment 10/11/22 Quarterly Tobacco Use Observation assessment, Description: Quarterly Assessment 11/22/22 Quarterly Tobacco Use Observation assessment, Description: Quarterly Assessment The next Quarterly Tobacco Use Observation assessment was due 02/22/23 and had not performed. The care plan reflects the following: Approach: Safe smoking assessment completed on admission, quarterly and as needed. Start Date 07/03/2021 On 04/25/23 at 8:30 AM and 12:30 PM, Resident #11 was observed smoking in the designated smoking area with staff supervision. The above information was confirmed with the Director of Nursing on 04/25/23 at 2:36 PM and she confirmed a quarterly smoking assessment should have been completed again in February of 2023 b) Resident #3 On 04/24/23 at 1:15 PM, observation found Nurse Aid (NA) #15 transferring Resident #3 from his geriatric chair to his bed using a lift. She was providing the transfer alone. This was confirmed with the NA and the Licensed Practical Nurse (LPN) #19 on 04/24/23 at 1:16 PM. Resident #3 is housed on the 2nd floor and the assigned staffing on that floor is one NA and one LPN. There are two (2) residents on the 2nd floor that require a lift for transfers. Record review of Resident #3's care plan shows he is a mechanical lift, two person assist with transfers. Use mechanical lift. According to the manufacturer (Drive) owners manual and instructions for a patient lift, it is stated numerous times that Drive recommends that two (2) attendants (One (1) on each side of the bed) be used when positioning the patient . According to an interview with the Director of Nursing on 04/25/23 at 11:15 AM, the facility does not do lift evaluations, nor does the physical therapist assess the residents for assistance in their physical abilities to determine their lift status. Per the DON's statement: The nurses use their common sense to determine if a resident requires a lift for transfers. .

. Based on observation, medical record review, and staff interview the facility failed to follow physicians' orders for ensuring the Foley Catheter collection bag was covered at all times. This was true for one (1) of one (1) resident reviewed for catheter care. Resident identifier: #107. Facility census 48. Findings included: a) Resident #107 Medical record review found the facility Physician ordered a urinary catheter bag cover to be used at all times on 04/19/23. During an observation on 04/24/23 at 2:46 PM, it was noted there was no privacy cover over the Foley catheter collection bag. On 04/24/23 at 2:47 PM Licensed Practical Nurse #53 said she would put a privacy cover on the urinary bag. .

. Based on record review and staff interviews the facility failed to offer pneumococcal immunizations to all residents. This was true for two (2) out of five (5) reviewed for immunizations. Resident Identifiers: #107, and #41. Facility census 48. Findings included: a) Resident #107 A review of the medical records for Resident #107 found no evidence the Resident received a pneumococcal vaccine. On 04/25/23 at 12:00 PM, the Infection Preventionist (IP) was asked if Resident #107 was offered the vaccine. The IP stated it was her understanding Resident #107 did not want the vaccine. At 1:45 PM on 04/26/23, the IP provided the Pneumococcal vaccination declination. Record review found Resident #107 has capacity; however, Registered Nurse (RN) #53 signed the forms instead of the Resident. There was no evidence to support that Resident #107 was offered and declined the vaccine. b) Resident #41 Resident #41 has been in the facility since 05/13/22. A review of the medical record found Resident #41 was not offered a pneumococcal vaccine. At 1:45 PM on 04/26/23, the IP stated she called the MPOA (Medical Power of Attorney) and asked if MPOA wanted Resident #41 to receive the pneumococcal vaccines. The IP said the MPOA would come tomorrow and sign a consent. .

. b) Resident #207 On 04/24/23 at 1:10 PM, during the initial interview phase of the Long Term Care Survey Process, Resident #207 had an isolation caddy and door bag for personal protective equipment (PPE.) Upon confirmation with Licensed Practical Nurse #19 she states the resident was in isolation for Methicillin-resistant Staphylococcus aureus (MRSA). There was no isolation sign on the door indicating what PPE is needed for staff and/or visitors. The resident should have been in contact precautions for MRSA, not standard precautions. This was also confirmed with the Infection Preventist on 04/24/23 at 2:10 PM. Further record review found the facility failed to develop a care plan to reflect the Resident is in contact isolation for MRSA. This was confirmed with the Director of nursing on 04/25/23 at 2:40 PM. Based on record review and staff interview the facility failed to complete infection surveillance for residents who are actively being treated for Multidrug-resistant organisms (MDRO.) In addition, the facility failed to track and trend other infections. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 48. Findings included: a) Infection surveillance Facility Policy titled, Infection Reporting no date was on the policy. --New orders for antibiotics or new lab orders, such as to obtain cultures, will be noted in the 24-hour shift report. --The nurse noting orders for transmission-based precautions will communicate the type of precautions (e.g., contact, droplet, airborne) ordered for resident, room number, to all departments, the Director of Nursing, Administrator, and the Infection Preventionist via the in-house communication form. --Transmission-based precautions will be noted with a sign on the residents door for the duration the resident is on transmission-based precautions. During an interview with Infection Preventionist (IP) on 04/25/23 at 12:37 PM, she was asked to review the current line listing (infection surveillance) log book. The IP stated she does not do surveillance of any infection unless they (the facility) are in a COVID-19 outbreak. The IP said she reports to the local Health department and the health department told her she did not have to do that. In addition, the IP stated she has been in the position of IP for three (3) months. At 1:50 PM, on 04/25/23, the IP said she found a log book with infections, but she was not hanlded the book until a week ago. The IP was asked about tracking and trending infections such as Urinary Tract Infections, and was asked what tool she uses to determine if an antibiotic was needed or not? The IP stated (name of the facility physician) does not like to use the McGeers tool so she does not use it. When asked if there was anyone in the facility that is currently on TBPs, she stated, no not at this time. The IP was informed there is a resident that is actively being treated for MDRO. The IP did not know what type of TBP the resident was placed in and said was most likely the Resident would be in standard precautions. After further questions, the IP stated she guesses Resident #207 should be in Contact isolation. During a meeting on 04/26/23 at 12:05 PM, with the Director of Nursing and Administrator, the DON stated the IP reported to the QAPPI committee on 04/17/23 that there were currently five (5) residents with infections. --Resident #117 with CDT Clostridium difficile (C. diff) in stool. --Resident #207 MRSA Methicillin-resistant Staphylococcus aureus in blood --Resident #124 ESBL extended-spectrum beta-lactamases in urine. --Resident #211 MRSA in Trach (this resident no longer has a trach.) --Resident #201 MRSA in nares On 04/26/23 at 12:07 PM, the IP was asked about these five (5) residents she reported in the building on 04/17/23. The IP said, oh no only one (1) person on the list is active. The other four (4) just have a history of those infections. The IP was asked if the four she listed are the only residents that have a history of having an MDRO? The IP said yes, that all just the four I listed. Observation of the first page of the Infection Tracking Log, completed by a staff member who is no longer employed at the facility found Resident #8 (who was not listed above) had ESBL. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review and staff interview the facility failed to provide the Resident the right to make choices concerning his Activities of Daily Living (ADL) care. This was true for one (1) of two (2) records reviewed for choices. Resident Identifier: #19. Facility Census: 40. Findings Included: a) Resident #19 On 10/10/22 at 1:29 PM during the initial interview phase of this survey, Resident #19 complained that he is not getting his showers as he would prefer. According to the Physicians Determination of Capacity dated 8/09/22 he has capacity to make his own decisions. A review on 10/11/22 at 10:00 AM of his care plan focus under ADL Functional Potential states a goal of Resident's care will be provided for based on their preferences and cognitive functional abilities evidenced by staff completing point of care [NAME] and updating as needed. On 10/11/22 at 10:05 AM during a review of the Point of Care (POC) history records since his admission on [DATE], he has had only three (3) showers through 10/10/22. The showers were documented in POC on the following dates: 9/05/22, 9/26/22 and 10/07/22. A partial bed baths or other baths were documented in POC on the following dates: 8/09/22 Partial bed bath 8/11/22 Partial bed bath 8/14/22 Partial bed bath 8/16/22 Other bed bath 8/18/22 Partial bed bath 8/21/22 Partial bed bath 8/30/22 Partial bed bath 9/01/22 Partial bed bath 9/04/22 Partial bed bath 9/08/22 Partial bed bath 9/10/22 Partial bed bath 9/15/22 Partial bed bath 9/24/22 Partial bed bath 9/27/22 Partial bed bath 10/02/22 Partial bed bath 10/08/22 Partial bed bath 10/10/22 Partial bed bath Activity did not occur was in documented in POC for the following dates: 8/06/22 8/07/22 8/08/22 8/13/22 8/15/22 8/20/22 8/22/22 8/24/22 8/25/22 8/27/22 8/28/22 8/29/22 9/02/22 9/06/22 9/07/22 9/12/22 9/13/22 9/14/22 9/16/22 9/17/22 9/18/22 9/19/22 9/21/22 9/22/22 9/23/22 9/28/22 9/29/22 10/01/22 10/04/22 10/06/22 10/09/22 This was confirmed with the Director Of Nursing on 10/12/22 at 8:45 AM at which time she stated she is unable to locate the Certified Nurse Aid sign off shower sheets. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to report residents who experienced serious bodily harm (fractures) to the appropriate state agencies. These were random opportunities of discovery. Resident identifiers: #1 and #18. Facility census: 40. Findings include: a) Resident #1 Resident #1's medical records found the resident was seen on 09/16/22 at 3:52 pm by the facility's Family Nurse Practitioner (FNP) as written on the FNP progress notes states, Resident was placed on rounds per staff for follow-up on resident-to- resident altercation today. Male resident was in the resident's room and resident and the male resident started hitting each other and the male grabbed her left arm and left extensive bruising. Resident is complaining of pain in left wrist. Residents are also complaining of acute chronic lower back pain radiating down the right leg . Plan: X-ray left wrist and lumbar spine . Review of Resident #1's X-ray reports as follows: Report date was 09/16/22 at 2:38- X-ray of left forearm and wrist are no fracture or dislocation noted. No acute abnormality seen. Further review found a report dated 09/16/22 at 2:47 pm- X-ray of lumbar spine results: There is mild to moderate compression fractures involving the thoracic twelve (T12), lumbar one (L1), lumbar two (L2), and lumbar three (L3) vertebral body of indeterminate age . Orders received from the FNP as follows: Neurosurgeon referral for maybe Kyphoplasty (a surgical procedure used to treat painful compression fractures in the spine). Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 10/11/22 at 3:10 pm. They both verified the fractures of the T12, L1, and L2, L3, noted on 09/16/22 for Resident #1, had not been reported to the appropriate state agency. b) Resident # 18 Review of Resident #18's medical records found an incident report, on 09/20/22 at 6:25 pm, read: The resident was found to be lying on the floor close to the facility's kitchen entrance by a facility staff member. The nurse went straight to the resident who was laying on her left side. When this nurse called the resident's name, she opened her eyes and started getting up. Resident seemed a little confused. Small bump on the left side of her forehead. Left arm upon examination also had two (2) small round bumps on the upper forearm close to her elbow. Resident was able to get up and ambulate to her room after sitting in a chair for a few minutes. She also stated her left hip was hurting her some. FNP was notified at 6:30 pm and ordered to be sent to the local emergency room for evaluation. Further review found an X-ray of the left hip with pelvis due to a fall with a complaint of low left groin pain done at local emergency room on [DATE] read: There is acute, mildly displaced fracture involving the superior as well as the inferior pubic rami (pelvis) . Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 10/11/22 at 3:20 pm. They both verified the fractures of the superior as well inferior pubic rami fracture, noted on 09/20/22 for Resident #18, had not been reported to the appropriate state agency. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to complete a discharge tracking form for Resident #3, when he left the faciity on [DATE] against medical advice (AMA) and for Resident #2's tracking form dated [DATE] was inaccurately coded as a death in facility, when in fact she was transferred to the local hospital and later died at the hospital. This deficient practice was noted in two (2) of three (3) late tracking assessments reviewed. Resident identifiers: #3 and #2. Facility census: 40. Findings include: a) Resident #3 Review of Resident #3's medical records found a nurse's note dated [DATE] read: Resident left facility AMA. Further review found no discharge tracking for Resident #3. Interview with the Director of Nursing on [DATE] at 2:00 pm, She confirmed there was not a discharge tracking form completed on [DATE] when he left the facility AMA. b) Resident #2 Review of Resident #2's medical records found a nurse's note read: On [DATE] at 5:58 PM. Resident was eating dinner and the nurse walked in and residents' oxygen dropped to 68%, BP 200/110, rattling in her chest noted. Shortness of breath (SOB) noted. Resident transferred to the local hospital for evaluation . Further review found her discharge assessment was coded death in the facility. Interview with the Director of Nursing on [DATE] at 2:15 pm, She confirmed the discharge tracking form was completed on [DATE] as a death in the facility. She confirmed it should have been coded and transferred to an acute care facility. .

. Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for two (2) of 18 residents reviewed in the long-term care survey sample. Resident identifiers: #20, and #1. Facility census: 40. Findings included: a) Resident #20 Review of Resident #20's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/14/22 stated the resident had received diuretic medication three (3) days during the look back period of seven (7) days. Review of Resident #20's Medication Administration Record (MAR) for 08/07/22 through 08/14/22 showed the resident received two (2) diuretic medications. The resident received Laxix (furosemide) every other day and Bumex (bumetanide) every day. During an interview on 10/11/22 at 3:35 PM, the Director of Nursing (DON) stated Resident #20's MDS assessment with ARD 08/14/22 was incorrect and should have stated the resident received seven (7) days of diuretic medication during the look-back period. No further information was provided through the completion of the survey process. b) Resident #1 Review of Resident #1's medical record found the resident had an incident on 07/17/22 at 10:21 pm, which read: Called to shower room and the resident was sitting on the floor next to the commode . Further record review of Resident #1's Minimum Data Set (MDS) with assessment reference date (ARD) of 07/17/22, found under section J falls found resident had not experienced any falls. Interview with the Director of Nursing (DON) on 10/11/22 at 2:20 pm. She verified the fall noted on 07/17/22 should have been coded on the MDS with ARD of 07/17/22 and was not coded correctly. .

. Based on observation, record review, and staff interview, the facility failed to ensure the comprehensive care plan was updated when a change occurred for one (1) of 18 residents reviewed in the long-term care survey sample. Resident identifier: #25. Facility census: 40. Findings included: a) Resident #25 On 10/11/22 at 11:58 AM, the Resident #25 was observed in the dining room being fed by a staff member. Review of Resident #25's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 09/06/22 showed the resident required total dependence for eating. Review of Resident #25's comprehensive care plan showed the problem of inability to maintain health state independently. The approaches included eating assistance and stated the resident could eat independently with cues. During an interview 10/11/22 at 3:35 PM, the Director of Nursing (DON) stated Resident #25 used to be able to feed herself with cues but now required total assistance. The DON confirmed Resident #25's comprehensive care plan had not been updated to show the resident required total assistance to eat. No further information was provided through the completion of the survey process. .

. Based on record review and staff interview, the facility failed to ensure monitoring of areas relating to nutritional status for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #25. Facility census: 40. Findings included: a) Resident #25 Review of Resident #25's Registered Dietician note dated 09/30/22 showed the resident was underweight at 95.8 pounds. The resident also had significant weight loss of 8% in the last 30 days. Review of Resident #25's physicians' orders showed an order written on 03/02/22 for weekly weights. Review of the resident's medical records showed no weight had been recorded for the week of 08/08/22 and for the week of 09/12/22. Further review of Resident #25's physicians' orders showed an order written on 08/18/22 for a house shake three (3) times a day. Review of the resident's medical records showed the amount of house shake consumed had only been documented two (2) times during the last 14 days. On 09/30/22 at 12:39 PM and on 10/07/22 at 12:43 PM, documentation showed the resident consumed 76-100% of the supplement. Review of Resident #25's meal intakes for the last 14 days showed meal consumption had not been documented for every meal. Meal consumptions had not been documented for the following dates and meals: - 09/28/22: breakfast and lunch - 09/29/22: dinner - 09/30/22: dinner - 10/01/22: breakfast, lunch, and dinner - 10/02/22: breakfast and dinner - 10/03/22: breakfast, lunch, and dinner - 10/04/22: dinner - 10/05/22: dinner - 10/06/22: breakfast, lunch, and dinner - 10/07/22: dinner - 10/09/22: breakfast During an interview on 10/11/22 at 3:35 PM, the Director of Nursing (DON) confirmed Resident's #25's weight had not been obtained on 08/08/22 and 09/12/22. The DON also confirmed Resident #25's meal and supplement consumptions had not been recorded at every opportunity. No further information was provided through the completion of the survey. .

. Based on medical record review and staff interview, the facility's consultant pharmacist failed to identify and report to the physician when the physician ordered parameters for medication was not followed. Resident identifiers: #36 and #38. Facility census: 40. Findings included: a) Resident #36 Review of Resident #36's medical records found an order for Clonidine (antihypertensive medication) read: Blood pressure daily. If systolic blood pressure (SBP) greater than 140; give Clonidine and recheck blood pressure for effectiveness and document. Give every 4 hours till the SBP returns to baseline below 140 (effective 05/22/22). Review of Resident #36's August, September, and October 2022 Medication admission Record (MAR) found on the following dates the SBP was greater than 140: --08/14/22 at 7:33 am- blood pressure- 153/71- Clonidine administered at 7:34 am with no follow-up blood pressure --08/10/22 at 8:52 am- blood pressure- 160/62- Clonidine administered at 8:57 am with no follow-up blood pressure. --08/20/22 at 7:17 am- blood pressure- 158/63- Clonidine not administered. --08/21/22 at 7:52 am- blood pressure- 143/61- Clonidine not administered --09/11/22 at 12:57 am- Blood pressure- 142/81. Clonidine not administered --09/17/22 at 7:54 am- blood pressure- 145/55. Clonidine not administered. --09/26/22 at 10:00 am- blood pressure- 192/92 Clonidine not administered --10/03/22 at 7:14 am- blood pressure- 147/87 Clonidine not administered --10/06/22 at 3:43 pm- blood pressure- 152/78 Clonidine not administered --10/07/22 at 7:17 am- blood pressure- 142/68 Clonidine not administered --10/10/22 at 7:32 am- blood pressure- 146/78 Clonidine not administered The consultant pharmacist did a monthly medication regimen review (MMRR) on 08/26/22 and 09/27/22 with no recommendations. During an interview with the Director of Nursing (DON) on 10/11/22 at 2:20 pm, Resident #36's MAR for August, September and October MARs were reviewed, and she confirmed the blood pressures and Clonidine was not completed and administered according to the physician ordered parameters. She confirmed the consultant pharmacist did not make any recommendation in August or September 2022. b) Resident #38 Review of Resident #38's physician orders found an order which read: Novolog u-100 insulin; give five (5) units subcutaneously before meals. Hold insulin if blood sugar is less than 140. Effective date 08/10/22. Review of Resident #38's August, September, and October 2022 Medication admission Record (MAR) found on the following dates the blood sugar (BS) was less than 140 and insulin was not held as ordered: 08/11/22 at 7:00 am BS 125. 08/13/22 at 11:00 am BS 108. 08/16/22 at 11:00 am BS 107. 08/18/22 at 11:00 am BS 110 09/01/22 at 7:00 am BS 137. 09/06/22 at 7:00 am BS132. 09/06/22 at 5:00 pm BS 106. 09/07/22 at 7:00 am BS 106 09/07/22 at 11:00 am BS 110. 09/08/22 at 7:00 am BS 95. 09/27/22 at 7:00 am BS 129. 09/27/22 at 5:00 pm BS112. 10/04/22 at 5:00 pm BS 119. 10/07/22 at 5:00 pm BS 128. 10/10/22 at 7:00 am BS 130 The consultant pharmacist did a monthly medication regimen review (MMRR) on 08/26/22 and 09/27/22 with no recommendations. During an interview with the Director of Nursing (DON) on 10/11/22 at 3:20 pm, Resident #38's MAR for August, September and October MARs were reviewed, and she confirmed the insulin before meals with the parameter to hold if BS was less than 140; was not administered according to the physician ordered parameters. She confirmed the consultant pharmacist did not make any recommendation in August or September 2022 .

. Based on observation, record review and staff interview, the facility failed to ensure expired facility stock medications were removed from the medication room. This was a random opportunity for discovery, and had the potential to affect an isolated number of residents. Facility Census: 40. Findings Included: a) Medication Room On 10/11/22 at 8:05 AM, the medication storage room was toured. The medication storage room tour found the following expired facility stock medications: --two (2) unopened boxes of antidiarrheal (Loperamide Hydrochloride 2mg) tablets with the expiration date of 09/2022 --one (1) unopened bottle of Nitroglycerin (NTG) 0.4mg tablets with the expiration date of 08/24/22 On 10/11/22 at 8:20 AM, Licensed Practical Nurse (LPN) #17 confirmed the medications were expired. On 10/11/22 at 8:35 AM, the Administrator was notified and confirmed the medications were expired. b) Facility Policy On 10/11/22 at 11:00 AM, the facility policy entitled Removal and Destruction of Expired Medications was reviewed. The policy states the following: --Medication carts and facility stock meds will be checked daily for expiration dates. Any medications that are expired will be removed from use and placed in the discontinued and expired medication receptacle in the medication room. (Typed as written.) No further information was obtained during the long-term survey process. .

. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered food was opened and not dated, missing floor tiles in the walk-in cooler and a dirty shelving unit. This practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 40. Finding included: a) Kitchen tour During the kitchen tour on 10/10/22 at 11:25 AM, it was discovered in the walk-in freezer, a package of english muffins were not dated after opening. Also in the walk-in cooler there were missing floor tiles. A dirty shelving unit had a large mixing bowl, a baking sheet, and two (2) steam table pans stored rim down on the heavily soiled shelves. An interview with the Dietary Manager on 10/10/22 at 11:35 AM, verified the english muffins were not dated after opening, and the shelving unit needed to be cleaned. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #10. This was true for one (1) of four (4) residents reviewed in the care area of hospitalizations. Resident #10. Facility Census: 40. Findings Included: a) Resident #10 On 10/12/22 at 12:58 PM, a record review was completed for Resident #10. The review found the resident had been hospitalized from [DATE] to 07/11/22. The resident was diagnosed with pneumonia (PNA) and a urinary tract infection (UTI). A progress note dated 07/11/22 at 10:00PM states the following: Resident returns to facility from (Name of acute care facility) at this time. No s/s (signs or symptoms) of distress or discomfort. Resident smiling and greeting other residents. Personal items and call system within hands reach. Will continue to monitor. New orders verified by (Name of the Facility Nurse Practitioner) continue prior medications and add the following: --Azithromycin (antibiotic) 250 mg (milligram) tab (tablet) qd (every day) x (times) 5 (five) days for pneumonia. Resident received the first dose tonight. (Typed as written) -- Cefdinir (antibiotic) 300 mg capsule BID (twice daily) x 10 days for pneumonia/UTI. Resident received the first dose tonight. (Typed as written.) --Culturelle (probiotic) - 1 (one) capsular (capsule) BID x 10 days. Resident received the first dose tonight. (Typed as written.) On 10/12/22 at 1:30 PM, the July 2022 medication administration record (MAR) was reviewed. The review found the three (3) prescribed medications were not documented for 07/11/22. An interview with the Director of Nursing (DON) on 10/12/22 at approximately 2:00 PM was completed. The DON stated, I'll call the pharmacy to verify if the medication was pulled from the pyxis (an automated medication dispensing system). The nurse thinks she pulled it but she cannot remember back to July. On 10/12/22 at approximately 2:45 PM, the DON stated the pharmacy verified the medication Azithromycin was pulled at 11:00 PM and the Cefdinir was pulled at 11:01 PM from the pyxis. The DON also stated the medications were given, the LPN (licensed practical nurse) didn't chart it on the MAR. The DON verified and confirmed the medications were not documented on the medication administration record. No further information was obtained during the long-term survey process. .

. Based on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated care plan for one (1) of one (1) residents reviewed for the care area of hospice during the Long Term Care Survey Process. The care plan for Resident #28 did not specify when and what services were to be provided by the hospice staff. Resident identifier: #28. Facility census: 40. Findings included: a) Resident #28 During a medical record review on 10/11/22 for Resident #28, it revealed the care plan did not include any information regarding when hospice nurse aides and nurses would visit and what specific services were to be provided. In an interview with the Nursing Home Administrator (NHA) on 10/11/22 at 12:45 PM, verified the care plan for Resident #28 did not specify care and services to be provided by the hospice staff. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations and staff interview, the facility failed to complete a comprehensive care plan for Resident #18 and #1, related to fractures. For three (3) residents the care plan was not implemented for Resident #23, concerning a smoking assessment, Resident #19 concerning showers and Resident #20 in area of weight changes. This was true for five (5) of eighteen (18) care plans reviewed. Resident identifiers: #18, #1, #23, #19, and #20. Facility census: 40. Findings include: a) Resident #18 Review of Resident #18's medical records found an incident report, on 09/20/22 at 6:25 pm, read: The resident was found to be lying on the floor close to the facility's kitchen entrance by a facility staff member. The nurse went straight to the resident who was laying on her left side. When this nurse called the resident's name, she opened her eyes and started getting up. Resident seemed a little confused. Small bump on the left side of her forehead. Left arm upon examination also had two (2) small round bumps on the upper forearm close to her elbow. Resident was able to get up and ambulate to her room after sitting in a chair for a few minutes. She also stated her left hip was hurting her some. FNP was notified at 6:30 pm and ordered to send to the local emergency room for evaluation. Further review found an X-ray of the left hip with pelvis due to a fall with a complaint of low left groin pain done at local emergency room on [DATE] read: There is acute, mildly displaced fracture involving the superior as well as the inferior pubic rami (pelvis) . Review of Resident #18's comprehensive care plan found no mention of the fracture. Interview with the Director of Nursing (DON) on 10/12/22 at 11:12 am. She verified no care plan was developed for Resident #18 in relation to this fracture. b) Resident #1 Resident #1's medical records found the resident was seen on 09/16/22 at 3:52 pm by the facility's Family Nurse Practitioner (FNP) as written on the FNP progress notes states, Resident was placed on rounds per staff for follow-up on resident-to- resident altercation today. Male resident was in the resident's room and resident and the male resident started hitting each other and the male grabbed her left arm and left extensive bruising. Resident is complaining of pain in left wrist. Residents are also complaining of acute chronic lower back pain radiating down the right leg . Plan: X-ray left wrist and lumbar spine . Review of Resident #1's X-ray reports as follows: Report date was 09/16/22 at 2:38 pm X-ray of left forearm and wrist are no fracture or dislocation noted. No acute abnormality seen. Further review found a report dated 09/16/22 at 2:47 pm- X-ray of lumbar spine results: There is mild to moderate compression fractures involving the thoracic twelve (T12), lumbar one (L1), lumbar two (L2), and lumbar three (L3) vertebral body of indeterminate age . Review of Resident #1's comprehensive care plan found no mention of fracture. During an interview with the DON on 10/12/22 at 11:30 am. she confirmed no care plan was developed for Resident #1 in relation to this fracture. c) Resident #23 On 10/10/22 at 12:15 PM while reviewing a list of current smoking Residents provided by the Administrator, it was noted Resident #23 is a smoker. On 10/11/22 at 10:00 AM while reviewing medical records, Resident #23 has current orders as follows: 1) Resident may smoke with supervision 2) Oxygen 2 Liters per minute via Nasal Cannula as needed. Medical Record review on 10/11/22 at 10:15 AM for Quarterly Tobacco Use Observation Assessment shows an assessment was completed on 6/15/22. On 10/11/22 at 10:20 AM review of the Resident Smoking Policy (not dated) states Residents who smoke will be assessed using the Smoking Observation Report to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all- Quarterly . According to the care plan under the Tobacco Use Focus which has a goal for the resident to be assisted to smoke safely at designated areas and at scheduled times through the next review. The Intervention is a safe smoking assessment completed on admission, quarterly, and as needed. On 10/11/22 at 2:55 PM, it was confirmed with the Director of Nursing the September, 2022 Quarterly Tobacco Use Observation Assessment was not completed and the care plan as developed was not being implemented. d) Resident #19 On 10/10/22 at 1:29 PM during the initial interview phase of this survey, Resident #19 complained that he is not getting his showers as he would prefer. According to the Physicians Determination of Capacity dated 8/09/22 he has capacity to make his own decisions. On 10/11/22 at 10:00 AM a review of his care plan focus under activities of daily living (ADL) Functional Potential has a goal of Resident's care will be provided for based on their preferences and cognitive functional abilities evidenced by staff completing point of care [NAME] and updating as needed. During a review on 10/11/22 at 10:05 AM of the Point of Care (POC) history records since his admission on [DATE] shows he has had only three (3) showers through 10/10/22. The showers were documented in POC on the following dates: 9/05/22, 9/26/22 and 10/07/22. A partial bed bath or other bath was documented in POC on the following dates: 8/09/22 Partial bed bath 8/11/22 Partial bed bath 8/14/22 Partial bed bath 8/16/22 Other bed bath 8/18/22 Partial bed bath 8/21/22 Partial bed bath 8/30/22 Partial bed bath 9/01/22 Partial bed bath 9/04/22 Partial bed bath 9/08/22 Partial bed bath 9/10/22 Partial bed bath 9/15/22 Partial bed bath 9/24/22 Partial bed bath 9/27/22 Partial bed bath 10/02/22 Partial bed bath 10/08/22 Partial bed bath 10/10/22 Partial bed bath Activity did not occur was in documented in POC for the following dates: 8/06/22- 08/08/22 8/13/22 8/15/22 8/20/22 8/22/22 8/24/22 8/25/22 8/27/22 - 08/29/22 9/02/22 9/06/22 9/07/22 9/12/22 - 9/14/22 9/16/22- 9/19/22 9/21/22 - 09/23/22 9/28/22 9/29/22 10/01/22 10/04/22 10/06/22 10/09/22 On 10/12/22 at 8:45 AM it was confirmed with the Director of Nursing the care plan as developed was not being implemented. e) Resident #20 Review of Resident #20's comprehensive care plan showed an approach to notify the physician and registered dietician of weight loss/gain greater than five (5) pounds. This approach was written for the problem areas of diabetes, dehydration/fluid maintenance, and kidney failure. Review of Resident #20's weights showed the resident weighed 185 pounds on 06/07/22 and weighed 192 pounds on 07/11/22. This was a weight gain of over five (5) pounds. Resident #20's medical records showed no documentation the physician and the registered dietician were notified regarding the resident's weight change. During an interview on 10/11/22 at 3:37 PM, the Director of Nursing confirmed there was no documentation the care plan approach to notify the physician and the registered dietician was implemented when Resident #20 gained over five (5) pounds on 07/11/22. No further information was provided through the completion of the survey process. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interviews the facility failed to clarify and/or follow physician orders according to professional standards. This was true for eight (8) of eighteen (18) residents reviewed. Resident identifiers: #36, #18, #1, #38, #22, #20, #19 and #8. Facility census: 40. Findings include: a) Resident #36 Review of Resident #36's medical records found an order for Clonidine (antihypertensive medication) read: Blood pressure daily. If systolic blood pressure (SBP) greater than 140; give Clonidine and recheck blood pressure for effectiveness and document. Give every 4 hours till the SBP returns to baseline below 140 (effective 05/22/22). Review of Resident #36's August, September, and October 2022 Medication admission Record (MAR) found on the following dates the SBP was greater than 140: 08/14/22 at 7:33 am- blood pressure- 153/71- Clonidine administered at 7:34 am with no follow-up blood pressure 08/10/22 at 8:52 am- blood pressure- 160/62- Clonidine administered at 8:57 am with no follow-up blood pressure. 08/20/22 at 7:17 am- blood pressure- 158/63- Clonidine not administered. 08/21/22 at 7:52 am- blood pressure- 143/61- Clonidine not administered 09/11/22 at 12:57 am- Blood pressure- 142/81. Clonidine not administered 09/17/22 at 7:54 am- blood pressure- 145/55. Clonidine not administered. 09/26/22 at 10:00 am- blood pressure- 192/92 Clonidine not administered 10/03/22 at 7:14 am- blood pressure- 147/87 Clonidine not administered 10/06/22 at 3:43 pm- blood pressure- 152/78 Clonidine not administered 10/07/22 at 7:17 am- blood pressure- 142/68 Clonidine not administered 10/10/22 at 7:32 am- blood pressure- 146/78 Clonidine not administered During an interview with the Director of Nursing (DON) on 10/11/22 at 2:20 pm, Resident #36's MAR for August, September and October MARs were reviewed, and she confirmed the blood pressures and Clonidine was not completed and administered according to the physician ordered parameters. b) Resident #18 Review of Resident #18's medical records found an incident report, on 09/20/22 at 6:25 pm, read: The resident was found to be lying on the floor close to the facility's kitchen entrance by a facility staff member. The nurse went straight to the resident who was laying on her left side. When this nurse called the resident's name, she opened her eyes and started getting up. Resident seemed a little confused. Small bump on the left side of her forehead. Left arm upon examination also had two (2) small round bumps on the upper forearm close to her elbow. Resident was able to get up and ambulate to her room after sitting in a chair for a few minutes. She also stated her left hip was hurting her some. FNP was notified at 6:30 pm and ordered to send to the local emergency room for evaluation. Further review found an X-ray of the left hip with pelvis due to a fall with complaint of low left groin pain done at local emergency room on [DATE] read: There is acute, mildly displaced fracture involving the superior as well as the inferior pubic rami (pelvis). Consult with orthopedics next week. Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 10/11/22 at 3:20 pm. They both verified the consult to follow up with orthopedics due fractures of the superior as well inferior pubic rai fracture, noted on 09/20/22 for Resident #18, had not been completed. c) Resident #1 Resident #1's medical records found the resident was seen on 09/16/22 at 3:52 pm by the facility's Family Nurse Practitioner (FNP) as written on the FNP progress notes states, Resident was placed on rounds per staff for follow-up on resident-to- resident altercation today. Male resident was in the resident's room and resident and the male resident started hitting each other and the male grabbed her left arm and left extensive bruising. Resident is complaining of pain in left wrist. Residents are also complaining of acute chronic lower back pain radiating down the right leg . Plan: X-ray left wrist and lumbar spine . Review of Resident #1's X-ray reports as follows: Report date was 09/16/22 at 2:38- X-ray of left forearm and wrist are no fracture or dislocation noted. No acute abnormality seen. Further review found a report dated 09/16/22 at 2:47 pm- X-ray of lumbar spine results: There is mild to moderate compression fractures involving the thoracic twelve (T12), lumbar one (L1), lumbar two (L2), and lumbar three (L3) vertebral body of indeterminate age . Orders received from the FNP as follows: Neurosurgeon referral for maybe Kyphoplasty (a surgical procedure used to treat painful compression fractures in the spine). Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 10/11/22 at 3:10 pm. They both verified the physician order for neurosurgeon referral for maybe Kyphoplasty (a surgical procedure used to treat painful compression fractures in the spine) had not been completed. d) Resident #38 1) weights Review of Resident #38's physician orders found an order which read: Monthly weights. Notify physicians of weight change greater and/or less than five (5) pounds (lbs.). Effective date 06/23/22. Review of Resident #38's weights found on the following dates the resident's weight was 5 lbs. or more weight gain and no indication the physician was notified: Weight on 06/06/22- 145 and on 06/27/22 weight 150# a 5-pound gain Weight on 07/19/22-153.6 and on 08/16/22 was 158.6- a 5-pound gain Weight on 08/16/22-158.6 and on 09/05/22 was 164.6- a 6-pound gain During an interview with the Director of Nursing (DON) on 10/11/22 at 3:20 pm, confirmed the physician was not notified when the monthly weights were five (5) lbs. or greater as instructed on the physician orders. 2) insulin Further review of Resident #38's physician orders found an order which read: Novolog u-100 insulin; give five (5) units subcutaneously before meals. Hold insulin if blood sugar is less than 140. Effective date 08/10/22. Review of Resident #38's August, September, and October 2022 Medication admission Record (MAR) found on the following dates the blood sugar (BS) was less than 140 and insulin was not held as ordered: 08/11/22 at 7:00 am BS 125. 08/13/22 at 11:00 am BS 108. 08/16/22 at 11:00 am BS 107. 08/18/22 at 11:00 am BS 110 09/01/22 at 7:00 am BS 137. 09/06/22 at 7:00 am BS132. 09/06/22 at 5:00 pm BS 106. 09/07/22 at 7:00 am BS 106 09/07/22 at 11:00 am BS 110. 09/08/22 at 7:00 am BS 95. 09/27/22 at 7:00 am BS 129. 09/27/22 at 5:00 pm BS112. 10/04/22 at 5:00 pm BS 119. 10/07/22 at 5:00 pm BS 128. 10/10/22 at 7:00 am BS 130 During an interview with the Director of Nursing (DON) on 10/11/22 at 3:20 pm, Resident #38's MAR for August, September and October MARs were reviewed, and she confirmed the insulin before meals with the parameter to hold if BS was less than 140; was not administered according to the physician ordered parameters. e) Resident #22 On 10/12/22 at 9:00 AM, a record review was completed for Resident #22. A progress note dated 10/05/22 at 3:23 PM read as follows: FNP (Facility Nurse Practitioner) in facility on rounds. New orders to obtain CBC (complete blood count), CMP (comprehensive metabolic panel) , A1C (hemoglobin A1C), TSH (thyroid stimulating hormone), Mg (magnesium level) on NLD (next lab day). Resident aware. (Typed as written.) In addition, a progress note dated 10/07/22 at 3:45 AM stated, CBC, CMP, A1C, TSH, Mg obtained via venipuncture x 1 (times one) attempt successful to left ac (antecubital region). Patient tolerated well. (Name of laboratory) informed for pick up. (Typed as written.) On 10/12/22 at 9:15 AM, a copy of the laboratory results were reviewed. The laboratory results received were the CMP and the Mg. At this time, the Director of Nursing (DON) was interviewed and asked where were the other laboratory results? The DON stated let me check and see where the results are. A new progress note dated 10/12/22 at 9:21 AM was found and stated, Spoke with FNP regarding routine labs new orders to obtain CBC, TSH, and A1C on NLD. RP (resident representative) made aware. (Typed as written.) On 10/12/22 at 10:50 AM the DON stated, they (CBC, A1C and TSH) got missed .the nurse contacted the nurse practitioner and reordered them .they were just routine labs. No further information was obtained during the long-term survey process. f) Resident #20 Review of Resident #20's physicians' orders showed orders for laboratory testing. A basic metabolic panel was to be performed on 10/03/22 and a basic metabolic panel and magnesium level was to be performed on 09/19/22. Resident #20's medical records showed no indication blood had been drawn for these laboratory tests. No laboratory results for these tests were located in Resident #20's medical records. During an interview on 10/11/22 at 3:35 PM, the Director of Nursing stated she could not locate results for Resident #20's laboratory tests ordered for 10/03/22 and 09/19/22. No further information was provided through the completion of the survey. g) Resident #19 On 10/12/22 at 8:31 AM during a review of the Physicians Orders, an order was noted for Hydralazine 1 tablet, 25 milligrams (mg) three times a day at 8:00 AM, 2:00 PM and 8:00 PM with perimeters to hold if systolic blood pressure is less than 110. On 10/12/22 at 8:40 AM a review of the Vitals Record and the Medication Administration History shows documentation on 8/19/22 the blood pressure was 108/76 and medication Hydralazine 25 mg was administered on 8/19/22 at 8:00 AM by Licensed Practical Nurse ##116. This was confirmed with the Director of Nursing on 10/12/22 at 8:43 AM that the Physicians order had not been followed as written. h) Resident #8 On 10/11/22 at 8:00 AM while observing Licensed Practical Nurse (LPN) #103 administer medications, she stepped away to address a tube feeding pump beeping in Resident #8's room. This surveyor observed the LPN add two (2) eight (8) ounce bottles of Osmolite 1.5 Cal to the tube feeding administration bag that was already hanging. Upon further observation at that time, it was noted that the tube feeding bag was dated 10/09/22. This was confirmed on 10/11/22 at 8:01 AM with LPN #103. According to the facility's Care and Treatment of Feeding Tubes policy dated 01/01/22, Direction for staff on how to provide the following care will be provided: use of infection control precautions and related techniques to minimize the risk of contamination . Professional standards of care requires the tube feeding bags and tubing be changed every twenty-four (24) hours. An interview on 10/11/22 at 11:10 AM with the Director of Nursing (DON) confirmed the tube feeding bag, tubing and syringe should be changed every 24 hours. .

. Based on observation, staff interview and policy and procedure review the facility failed to maintain an environment free of accident hazards. These were random oppurtunities for discovery and had the potential affect more than a limited number of residents. Resident Identifier: #23. Facility Census: 40. Findings Included: a) Resident #23 On 10/10/22 at 12:15 PM while reviewing a list of current smoking Residents provided by the Administrator, it was noted Resident #23 was a smoker. On 10/11/22 at 10:00 AM a reviewed of Resident #23's medical records found the following orders 1) Resident may smoke with supervision 2) Oxygen 2 Liters per minute via Nasal Cannula as needed. Medical Record review for Quarterly Tobacco Use Observation Assessment shows an assessment was completed on 6/15/22. Review of the facility's Resident Smoking Policy (not dated) states Residents who smoke will be assessed using the Smoking Observation Report to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all Quarterly . According to the Physician's Determination of Capacity dated 6/03/22 Resident #23 is incapacitated. During an interview with the Director of Nursing on 10/11/22 at 2:00 PM she confirmed, there should have been another assessment completed in September 2022 for the next quarter which was not completed. b) Facility On 10/11/22 at 8:00 AM, a medication cart was noted sitting in the hallway unlocked and unattended. Licensed Practical Nurse (LPN) #103 was found to be in another resident's room administering medications. When LPN #103 returned to the medication cart at 8:01 am, she confirmed the cart was not locked and should have been when she walked away. According to the facility Security of Medication Cart policy Revision 1:1: 1) The nurse must secure the medication cart during the medication pass to prevent unauthorized entry and 4) Medication carts must be securely locked at all times when out of the nurse's view. According to a list provided by the Director of Nursing (DON) there are four (4) Residents at risk for wandering in the facility. These Residents are #6, #17, #21 and #28. This was confirmed with the DON on 10/11/22 at 9:45 AM. c) Unlocked medication cart During a random opportunity for discovery on 10/12/22 at 8:48 AM, the medication cart for the Short hallway had been left unlocked while Licensed Practical Nurse (LPN) # 101 was in a resident's room administering a nebulizer treatment. The medication cart was not in her line of sight. An interview with LPN #101 on 10/12/22 at 8:50 AM, confirmed the medication cart had been left unlocked while she was administering a nebulizer treatment. .

. Based on record review and staff interview, the facility failed to ensure the controlled substance count was completed and documented by two (2) nurses during shift change. This was a random opportunity for discovery. Facility Census: 40. Findings Included: a) Medication Administration On 10/11/22 at 8:20 AM, a review of the controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change: --09/09/22 on-coming nurse did not sign. --09/10/22 off-going nurse did not sign --09/18/22 on-coming nurse did not sign --09/18/22 off-going nurse did not sign --09/22/22 off-going nurse did not sign --09/28/22 off-going nurse did not sign --09/29/22 on-coming nurse did not sign --09/29/22 off-going nurse did not sign --10/04/22 on-coming nurse did not sign --10/06/22 on-coming nurse did not sign On 10/11/22 at 8:20 AM, Licensed Practical Nurse (LPN) #17 confirmed the narcotic count book was not signed by two (2) nurses on the above dates. On 10/11/22 at 8:35 AM, the Administrator was notified and confirmed the above dates were not signed by two (2) nurses at the end of each shift. b) Facility Policy On 10/11/22 at 10:00 AM, a review of the facility policy entitled Controlled Substances was completed. Under the heading Interpretation and Implementation number nine (9) states the following: --Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. No further information was obtained during the long-term survey process. .

. Based on record review and staff interview, the Quality Assessment and Assurance Committee failed to develop and implement appropriate plans of action to correct identified quality deficiencies. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 40. Findings included: A) Cross Reference F684 Findings b, c, e, and F. B) Interview During an interview on 10/12/22 at 2:01 PM, the Director of Nursing (DON) stated the Quality Assessment and Assurance (QAA) Committee had identified a problem with laboratory testing. The DON stated the unit charge nurse was supposed to check orders for laboratory testing daily. The charge nurse was to insure and document that the laboratory samples were obtained. The DON also stated the QAA Committee had identified a problem with the scheduling of resident appointments with outside medical providers. The DON stated the unit clerk was supposed to schedule these appointments. .

. Based on record review and staff interview, the facility failed to ensure documentation of notification to resident representatives when a staff member tested positive for COVID-19, beginning an outbreak. This was true for three (3) of three (3) residents reviewed for COVID-19 notification. Resident #25, Resident #27, Resident #6. Facility census: 40. a) Resident #25 Review of the facility's COVID-19 line listing showed a facility outbreak began on 06/27/22 when a staff member tested positive for COVID-19. Resident #25 lacked capacity to make medical decisions. Review of Resident #25's medical records for 06/27/22 through 06/28/22 did not show any documentation that the resident's representative was notified regarding the COVID-19 outbreak beginning on 06/27/22. b) Resident #27 Review of the facility's COVID-19 line listing showed a facility outbreak began on 06/27/22 when a staff member tested positive for COVID-19. Resident #27 lacked capacity to make medical decisions. Review of Resident #25's medical records for 06/27/22 through 06/28/22 did not show any documentation that the resident's representative was notified regarding the COVID-19 outbreak beginning on 06/27/22. c) Resident #6 Review of the facility's COVID-19 line listing showed a facility outbreak began on 06/27/22 when a staff member tested positive for COVID-19. Resident #6 lacked capacity to make medical decisions. Review of Resident #6's medical records for 06/27/22 through 06/28/22 did not show any documentation that the resident's representative was notified regarding the COVID-19 outbreak beginning on 06/27/22. d) Interviews During an interview on 10/12/22 at 10:14 AM, the Director of Nursing (DON) stated resident representatives were notified by text messaging about the COVID-19 outbreak beginning on 06/27/22. The DON did not know how resident representative without text messaging availability would have been notified. During an interview on 12/12/22 at 10:59 AM, the facility Administrator stated a sign was placed at the facility entrance when the COVID-19 outbreak began on 06/27/22. This sign gave notification that the facility was in outbreak and outlined the precautions that should have been taken by visitors. The Administrator stated a notification about the outbreak was sent by text message. The Administrator stated there was a list of resident representatives to call about the COVID-19 outbreak because they did not have text messaging. However, the Administrator stated she no longer had this list. Specifically, the Administrator was unable to locate any documentation that Resident #25, #27, and #6's resident representatives were notified about the COVID-19 outbreak beginning on 06/27/22. No further information was provided through the completion of the survey. .